Tackling the Doctor Shortage in Ontario, Canada

It is now the rule, not the exception, to live in a community that does not have enough family physicians to care for all its citizens. In hospitals, the situation is just as grim, with difficulties staffing emergency departments and long waiting lists for specialist services.Numerous factors have contributed to this province-wide physician shortage and the statistics projected for physician availability during the coming years are not encouraging. In fact, further decreases in the number of family physicians and specialists are anticipated over the next decade.The College of Physicians & Surgeons of Ontario (College) believes decisive action must now be taken in addressing the doctor shortage. To that end, Council has drawn up a list of recommendations increasing the number of physicians who can practice in Ontario.“The College’s top priority is to tackle the doctor shortage to ensure that the citizens of Ontario have access to quality health care,” said Dr. Barry Adams, president of the College. “We are committed to reducing barriers to the recruitment, registration, training and education of doctors in this province.”The College began developing strategies to provide greater opportunities for physicians to qualify to practice in this province as early as 1998. However, the College is concerned the momentum created by recent successes will be lost unless further, more aggressive, action is taken. The recommendations in this article build on the significant work done by previous task forces.“Tackling the Doctor Shortage” identifies areas where action can be taken to deal effectively with the physician resource challenge.For example, the supply of physicians in Ontario could be significantly improved by expanding the number of assessment and training positions for international medical graduates.“It is key to make sure that we have an assessment process that is accessible and fair, coupled with enough training positions to accommodate all successful candidates,” said Dr. Adams.The report also includes a number of recommendations to introduce more flexibility in recognizing equivalent examinations and certifications and urges government to plan effectively for future supply and demand by appointing a Health Human Resource Planning body.“We have worked from the premise that all solutions must maintain our existing standards of registration. We believe that the solutions we propose will not compromise the high-quality care Ontarians expect and deserve from their health care providers,” said Dr. Adams.Significant steps have been taken to increase the supply of physicians in Ontario. While each accomplishment will help to increase patient access to Ontario doctors, the shortage is so severe in scope that far greater action is warranted.We urge the government to consider the following: Assess the qualifications of all international medical graduates;significantly expand available training opportunities;maximize existing resources and eliminate existing barriers; and,plan for the future.Ontario has hundreds of physicians who have immigrated to this province with a medical degree from a non-North American school and are unable to practice here. There are also approximately 200 Ontarians who graduate each year from medical schools outside of Canada. Both groups are needed in Ontario and have been frustrated by the lack of available assessment opportunities to enable them to qualify to practice here.Assessment opportunities should be made available for every eligible international medical graduate (IMG) who lives in Ontario and for Canadian citizens who have completed medical training abroad. This assessment should set a fair and transparent standard using objective methods, and successful candidates should be provided with an assessment/training position in an Ontario program.Eligible international medical graduates have educational degrees and practice experience in other countries. Because of the huge variations in international education standards and in medical practices across jurisdictions, it is impossible for the College, simply by looking at credentials, to determine whether the skills of IMG applicants meet Ontario expectations for quality of care. Accordingly, most IMGs must undergo testing and assessment equivalent to those undertaken by all Canadian graduates to certify the level of their skills.Ontario continues to have too few available spots for assessment of IMGs. Currently, there are only 50 specialist assessment positions available each year. In addition, the current assessments rank candidates in relation to others, and only the top achievers are eligible to continue with their training.Many IMGs may meet acceptable clinical standards and are willing to upgrade their training, but they are ineligible because others scored higher on the testing and because of the limited number of training positions available. Furthermore, the candidates themselves cannot determine whether they have deficits in their knowledge and, if so, where those deficits may be.In order to maximize use of this potential human resource, it is critical that within the next two years,assessments be made available for all IMGs who meet simple eligibility criteria. The assessment itself should rely on validated tools for evaluation and the detailed results should be available to the candidate. There should also be enough training positions to accommodate all successful candidates.Access to additional assessment and training opportunities should be facilitated through the Ontario International Medical Graduate Clearinghouse.Addressing the potential backlog of IMGs who may be capable of providing quality care to Ontario residents in this fashion would satisfy the frustration experienced by the IMG community related to the uncertainty of the current assessment process.Assessment and training positions should also be made available for Ontario students studying at international medical schools who wish to return to Ontario.Expanding training opportunities for international medical graduates is a key element of the physician resource solution. While training positions for undergraduate and postgraduate programs have been increased over the past few years, more positions are required. In addition, training opportunities must be provided for IMGs as they move through the assessment and training processes in order to help ensure their success and understanding of Ontario’s health care system.Develop guidelines to encourage IMGs to engage in observation of patient care (shadowing) in a clinical setting with members of the College.Candidates for registration who are already in the province would be better prepared for assessments if they were able to gain experience by observing the work of Ontario physicians in a clinical setting. There is, in fact, no barrier to this taking place now. However, many physicians are reluctant to allow IMGs into such a setting because they are concerned that doing so would breach College policy.The College proposes to disseminate guidelines that would make it clear that such arrangements are permissible. The guidelines would include a requirement of patient consent, a confidentiality agreement from the IMGs, and a stipulation that the supervising physician is responsible for the IMG’s actions at all times.In conjunction with all stakeholders, facilitate the development and implementation of web-based educational and assessment tools to teach legal and ethical issues and language and communications skills to potential Ontario physicians.As discussed above, the training and practice experience of IMGs is often very different from the practice of medicine in Ontario. This extends to the ethical and legal aspects of practice, as well as to clinical performance. The College proposes that, to assist IMGs to prepare for assessment in Ontario, web-based legal and ethical training tools should be developed that IMGs could use on their own time.On a long-term basis, the postgraduate training capacity be increased to a factor of 1.2 times the number of students graduating from Ontario medical schools, in addition to an increase for the next two or three years to accommodate everyone qualified for the proposed assessment and training opportunities.The primary factor leading to the dramatic decrease in production of physicians (in combination with the decreased medical school enrollment) was the decrease in postgraduate training positions. There were only enough spots to accommodate Ontario graduates. Consequently those from other jurisdictions, or those who were practicing in Ontario but wished to change fields, had to compete with new graduates for residency positions.While the number of post-graduate training positions has recently been increased, there is still a shortage of positions in relation to potential candidates. The number of training positions must be increased to accommodate more candidates. This initiative should be considered complementary to, and not a substitute for, the other recommendations in this paper.The College believes that, even within the province, we can make better use of the resources that we have. In some cases, improvement may be as simple as changing a regulation. In other instances, enhancements will require a strong concerted effort from all stakeholders.Introduce more flexibility in the process by which candidates both select and are allowed to switch postgraduate training positions.In the past, many specialties relied on receiving either students transferring from generic training programs or experienced family practitioners applying to train in specialty fields, rather than accepting only candidates directly from undergraduate medical school. The ability of family practitioners to make this transition has been severely weakened in recent years. As a result, students who are not certain about their ultimate career paths choose to pursue specialties, from which they can more easily switch back to family practice if they later decide on that career path. This policy shift appears to have exacerbated the marked decrease in the number of students selecting family practice.While this problem has been partially addressed by an increase in the availability of re-entry positions, the conditions on re-entry continue to serve as a barrier. The College recommends a further increase in the number of training positions for this sub-category of candidates, as well as a careful analysis of the accreditation system currently in place. In the College’s view, the practice of family medicine may be undervalued and may warrant increased recognition in relation to specialty training requirements.a) Explore recognition of the Unites States Medical Licensing Examination (USMLE), National Board of Osteopathic Medical Examiners (NBOME), Federation Licensing Examination (FLEX), Educational Commission for Foreign Medical Graduates (ECFMG) and Comprehensive Osteopathic Medical Licensing Examination (COMLEX) immediately as equivalent to the Medical Council of Canada Qualifying Examination (MCCQE) for purposes of registration.The College believes the standards set by these examinations are equivalent to our own Ontario standards. Accordingly, we should recognize them as such and require no further training or assessment of applicants who hold these qualifications.b) Develop a process to evaluate screening examinations from a variety of jurisdictions to determine whether they are equivalent to those in Canada.The College is aware there is a pool of well-trained competent physicians who wish to practice in Ontario but whose training and education comes from institutions whose standards are unknown to us. Rather than require such individuals to repeat testing and training, a more efficient way of determining whether such physicians meet the standards expected in Ontario would be to look closely at their education and training and determine whether it is equivalent to programs that the College already recognizes. This should be done in collaboration with other stakeholders.Create an entry pathway for physicians who were eligible for registration in the past, but whose eligibility was lost as a result of changing regulations.There are a number of physicians who are practicing in other Canadian jurisdictions who would have qualified for an Ontario certificate of registration had they applied prior to 1992 but who do not qualify under today’s regulations. These are primarily family physicians whose education included a rotating internship, which is no longer part of the Ontario medical education process. These physicians are welcome in other provinces and a significant number of exemplary physicians in Ontario have precisely these credentials.The College is willing to amend its regulation/policy to facilitate the re-entry of this population into Ontario. To guarantee quality of care, there should be a mechanism to assess candidates prior to their receipt of an unrestricted certificate of registration.a) Develop a process to recognize specialists who have specialty certification in their own jurisdictions and training in Accreditation Council for Graduate Medical Education (ACGME) recognized programs equivalent to Royal College requirements.Under our current system, physicians recognized as specialists in the United States are not recognized as such in Ontario. In order to receive specialty designation in Ontario, these individuals are required to successfully challenge the certification examination of the RCPSC. Having to complete these requirements is a deterrent for specialists who might otherwise wish to practice here. Academic centers benefit from the expertise of specialists from other jurisdictions through the academic registration certification.Similarly, physicians in Quebec may take specialty examinations and training equivalent to the RCPSC requirements. Currently, their qualifications are not recognized in Ontario.The College proposes that our registration standards would not be compromised if we assured ourselves a physician recognized as a specialist in the United States had received training equivalent to that required by the RCPSC and have been successful in their ABMS examination. This applies equally to those Quebec physicians who fall into the category described above and have been successful with the Quebec exam.The College could amend its regulation/policy to facilitate the recognition of this population. To ensure quality of care, there should be a mechanism to assess candidates prior to their receipt of an unrestricted certificate of registration.b) The CPSO should develop a process to recognize specialty training from non-American Council for Graduate Medical Education (ACGME) approved programs. The CPSO should develop a mechanism to recognize physicians certified as specialists in their country of practice whose training was completed in a program accredited by the Royal College of Physicians and Surgeons of Canada (RCPSC).The RCPSC has assessed a number of residency programs and deemed them to be equivalent to Canadian standards.The College proposes individuals whose training took place in an RCPSC-recognized program be considered for eligibility to practice in Ontario and to be recognized as specialists. To ensure quality of care, there should be a mechanism to assess candidates prior to their receipt of an unrestricted certificate of registration, and to ensure the validity of this new policy, an appropriate follow up would need to be undertaken.The Academic Health Sciences centers (AHSCs) should develop a mechanism acceptable to the College to assess physicians who are specialists in their country of practice who wish to come to Ontario and practice in an AHSC and who do not currently meet the criteria for academic registration.There is a population of physician specialists currently in practice under academic registration whose certificates of registration will expire within the next few years. These individuals have been practicing in Ontario under supervision and there is no doubt about the quality of care they provide. Requiring these people to undergo the usual process to receive an Ontario certificate of registration could be seen as duplicative, since their capabilities in known settings could, if made explicit, provide a basis for the recognition of their full status. This recognition would avoid a cumbersome process that would be a disincentive for these physicians to remain in Ontario. It is possible to ensure practice performance in the absence of usual credentials.The College is prepared to provide a certificate of registration permitting successful candidates to practice within the scope of their specialty if a satisfactory assessment process can be developed and implemented.Introduce a two-year pilot program allowing residents to provide service on a remunerated basis outside their educational program.Ontario residents are another valuable human resource whose full potential has not yet been realized. Over the last several years, there has been extensive discussion about residents working additional shifts for compensation. 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As a result of this physicians are now practicing or will be In approximately IMGs have practicing medicine in Ontario during the past College Council the physician resource as a top priority and in its In of this the College facilitated the of the is of from the of Health and Council of Ontario of Ontario Medical and the The has from the College of Physicians of the Royal College of Physicians and Surgeons of the of and of Ontario, the National on IMG and the of International Physicians and Surgeons of the recommendations at reducing barriers to the recruitment, registration, education and training of physicians in Ontario. The government of Ontario has of the is a of action that has been taken to to the recommendations of the has been created to assist physician applicants through the registration, and assessment number of postgraduate training programs has increased, allowing some qualified candidates access where positions were government of Ontario has increased for educational and capacity to the increase in the number of training positions that have been approved school College has an assessment and quality program to provide registration for physicians who are currently in practice in other jurisdictions and wish to practice in College has a policy to recognize medicine specialists who have critical educational and criteria but have not received the Royal College of and specialist continues to develop solutions to the physician resource The task is also to that have been by the Doctor Shortage” in the of by The College of Physicians & Surgeons of Ontario.

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