You are here: Home > The Transition to National Medical Licensure Standards > A Letter from the Registrar

Whats New...

A Letter from the Registrar

Observations on the transition to national medical licensure standards in Canada

Dr. D. A. Kendel, Registrar
College of Physicians and Surgeons of Saskatchewan

When the provincial/territorial members of the Federation of Medical Regulatory Authorities of Canada (FMRAC) made a collective decision to define common national standards for medical licensure across Canada, FMRAC established a Steering Committee to lead this process.

Initially the FMRAC Steering Committee articulated a broad set of principles which it considered appropriate to guide and inform the development of national medical licensure standards. At the FMRAC Annual Meeting convened in Halifax in June 2009, those principles were affirmed by all of the members of FMRAC with the exception of the College of Physicians and Surgeons of New Brunswick which did not participate in the meeting.

On the basis of feedback received at the FMRAC Annual Meeting, the Steering Committee further refined these principles and has now translated them into a draft agreement which was signed by all of the Registrars except for New Brunswick. A copy of the draft agreement is available on the College website (http://www.quadrant.net/cpss/).

Forging a national consensus on any policy issue in Canada is difficult as there are often deeply rooted regional differences in perspective. Consensus building always requires the parties engaged in the process to be sensitive and responsive to the perspective of others. It requires flexibility in search for common ground.

The Steering Committee had no difficulty in readily defining the "Canadian standard" for licensure eligibility in Canada which requires acquisition of the LMCC and discipline specific certification from either the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada. This standard has been a functional reality for several decades and is the pathway for licensure followed by all domestic medical graduates.

However, the Steering Committee reached a conclusion that requiring all International Medical Graduates (IMG's) to successfully complete the full series of examinations leading to these Canadian credentials is not appropriate. These examinations were explicitly developed to measure knowledge and skills as Canadian medical students and residents move progressively through the continuum of education leading to licensure eligibility. They not well suited to the measurement of physician competence at mid career.

The Steering Committee reached a consensus that it is reasonable and appropriate to require all IMG licensure applicants to confirm that they possess foundational medical knowledge through successful completion of a screening exam such as the Medical Council of Canada Evaluating Exam (MCCEE) or an equivalent standardized examination. However, the IMG evaluation tools and procedures used beyond this basic screening examination need to be more "fit for purpose". The Steering Committee took the position that this should be a practice assessment which it defined as "a comprehensive clinical assessment" (the format and content of which will be agreed and approved by FMRAC and it's members).

The Steering Committee recognized that practice assessments designed in different provinces may vary somewhat but they must have sufficient rigor and commonality so that all of the MRAs can have confidence that an IMG licensed for practice in Canada through such as practice assessment is competent to practice anywhere in the country. FMRAC has established a working group to define the format and content of practice assessments that FMRAC will approve.

The Steering Committee also reached a consensus position that there must be a mechanism in each province and territory for provisionally licensed IMGs to obtain full licensure through a process that does not necessarily require successful completion of the examinations currently offered by the Medical Council of Canada, the Royal College of Physicians and Surgeons, and the College of Family Physicians of Canada. Of course, every IMG will always have the option of acquiring full licensure through successful completion of those examinations and acquisition of the credentials associated with those examinations. However, IMGs should also have an opportunity to acquire full licensure through:

  1. Satisfactorily completion of a period of supervision in a Canadian jurisdiction, and;

  2. Satisfactorily completion of a summative practice assessment in a Canadian jurisdiction.

FMRAC has also established a working group to define acceptable criteria for supervision and summative practice assessment.

Implementaion of this Agreement in all MRA'S across Canada.

There is currently an extremely diverse array of medical licensure policies and procedures in place across Canada. There are strengths and weaknesses inherent in the policies and procedures in every jurisdiction.

It was not possible for the Steering Committee at this moment to identify IMG assessment and licensure policies in any single Canadian province or territory which it considers so ideal that those should be the benchmark for all other provinces and territories.

Achieving national compliance with the licensure standards implicit in the FMRAC Agreement will require some change in policy and practices in every jurisdiction. The requisite changes in some jurisdictions will be more profound than in others.

In some jurisdictions alignment with national standards may be achievable through modification of bylaws, regulations, and/or policies. In other jurisdictions, statutory amendments will be required.

Managing this change process will require decisive effective leadership on the part of each college Registrar and his/her respective governing council. It will also require the support of all of the provincial and territorial governments.

Although national medical licensure standards have been an aspirational goal in Canada since Confederation, this has proven to be a very elusive goal. To this point in history there has been little incentive for individual provinces and territories to find "common ground".

The Labour Mobility guarantees for physicians inherent in the revised Agreement on Internal Trade now provides a very strong incentive for all provinces and territories to find "common ground" for future medical licensure standards. The AIT itself does not compel provinces and territories to adopt common licensure standards. However, there is no doubt that life would be infinitely more harmonious for individual physicians, Colleges of Physicians and Surgeons, and their respective provincial territorial governments if there were common medical licensure standards across the country. This would eliminate the endless claims and counter-claims that polices in any particular jurisdiction are too lax, too onerous or too inflexible. Citizens across Canada would also be assured of uniform competence in the medical practitioners they rely upon for professional care.

Implications of the agreement for future IMG assessment and licensure policies and practices in Saskatchewan

In simplistic terms, these are the key changes that will need to occur in IMG assessment and licensure policies and practices in Saskatchewan to achieve compliance with the national agreement:

  1. The College of Physicians and Surgeons will need to adopt bylaws which make successful completion of the MCCEE (or an equivalent screening examination) a prerequisite for IMG eligibility for "provisional" licensure. The implementation timing for this policy will need to coincide with the availability of practice assessment capacity as described in the FMRAC Agreement.

  2. The Province of Saskatchewan will need to build local capacity and/or acquire access to extra provincial capacity for IMG practice assessment which will meet FMRAC standards (yet to be defined).

  3. The Province of Saskatchewan will need to develop capacity for effective practice supervision and summative practice evaluation which will enable provisionally IMGs to transition to full licensure.

  4. The College of Physicians and Surgeons will need to modify all existing bylaws which make acquisition of the LMCC and/or Royal College certification a requirement for enduring IMG registration in Saskatchewan.

In pragmatic terms, we cannot make a complete transition to these new policies until the requisite assessment capacity is not only developed but is functional. However, we also need to be mindful of the time delay that is inherent in drafting bylaw amendments, undertaking stakeholder consultations, and having those bylaws approved by the Minister of Health. Therefore, if we want to avoid the risk of bylaw amendments becoming the "rate limiting step" in the transition to the national licensure standards, we need to proceed with the drafting of appropriate bylaws and consultation in respect to those draft bylaws in a timely manner.

The Council of the College of Physicians and Surgeons in Saskatchewan has already directed the Registrar's Office to utilize an alternative temporary licensure option for IMG Specialists who lose their Royal College Certification eligibility. The Council will need to re-visit this strategy and ensure that the strategy is equally applicable to all IMGs who would lose their continuing registration eligibility as a consequence of failure to acquire Canadian credentials which will no longer be necessary under the envisioned future licensure policies.

Yours truly,

Dr. D. Kendel
Registrar CPSS