To ease shortage, Ontario must expand pathways to licensure for internationally trained physicians

Millions of Ontarians without a family doctor. Emergency departments closing. Surgeries and procedures delayed and cancelled. What we are witnessing is the collapse of our health-care system.

While COVID is partly to blame, the pandemic has exacerbated long-standing issues, including poor working conditions and high rates of stress, burnout and turnover. The crisis that has been building for years is exploding.

Physician services are a foundation of the health-care system but Canada isn’t training, licensing or retaining enough physicians (especially family physicians) to meet growing demands. Thousands of physicians will be needed throughout the country in coming years; there already are urgent needs in some underserved communities.

It is tragic that thousands of internationally trained physicians (ITPs) who have settled in Ontario in recent years face barriers to becoming licensed and applying their skills.

Some ITPs bring decades of clinical experience, including in family medicine, but there are too few assessment and credentialing pathways for them to return to practice. The result is widespread underutilization of medical training, and a lose-lose situation for both ITPs and the Canadian health system.

More than 3,600 physicians have become permanent residents since 2015 but statistics suggest that a great majority of these individuals have not been able to practice medicine in Canada, highlighting a profound disconnect between Canadian economic immigration policies that prioritize and reward education and work experience and the inadequate access to licensing pathways for internationally educated health-care workers.

It’s a gross waste of human capital and arguably a human-rights violation.

The good news is that practical, proven solutions exist that, if taken together, can have an immediate impact in reducing skills underutilization and boosting the supply of qualified health professionals.

A first measure would be for Ontario to implement a model called Practice-Ready Assessment (PRA) at an appropriate scale. Through this model, ITPs are assessed by a supervising physician over several months to gauge their “practice readiness;” successful PRA candidates are granted an independent licence and must practice in an underserved community for two to three years in a “return of service.”

PRA is being implemented in seven provinces, but only a few hundred ITPs have become licensed through this pathway in recent years. For PRA to have an impact, it needs to be implemented at an appropriate scale with appropriate investments to ensure that supervising physicians have time and capacity to assess candidates.

In Ontario, plans were announced in December 2022 to introduce PRA; details on cost and timing, however, have yet to be outlined. British Columbia recently announced plans to triple the number of PRA positions in the province in combination with significant reforms to its physician compensation model. Best practices in other provinces should inform an approach in Ontario.

A second measure would be increasing access to residency training for ITPs. Access is extremely limited for those with international medical degrees. In 2022, only 23.9 per cent of ITPs (including Canadians who studied abroad) were matched to residency in the Main Residency Match compared with 92 per cent for Canadian medical graduates. In 2022, 1,395 ITPs who applied for residency training positions (meaning they have fully met the educational and exam requirements) across Canada were unsuccessful in obtaining one.

Both the Ontario Medical Association and the Canadian Medical Association have called for an expansion of residency seats for ITPs. However, many actors are involved in the governance and implementation of medical residency training, adding complexity to the discussion on “simply expanding the number of residency seats.” Provincial ministries of health designate an “appropriate” number of positions in collaboration with the Association of Faculties of Medicine of Canada (AFMC). The Canadian Residency Matching Service (CaRMS) matches candidates to positions through a structured application process. Medical schools provide training; preceptors (independent physicians) supervise residents; and provincial regulatory bodies grant the licences required to train and practice. This complex ecosystem means that all voices need to be at the table to redesign an equitable plan going forward.

All voices need to be at the table to redesign an equitable plan going forward.

A third, important measure would be to establish a licensed Clinical Assistant (CA) role in Ontario that can support a pathway to independent licensure for ITPs. Like Physician Assistants, CAs work as physician-extenders and add capacity to care teams working under the supervision of a fully licensed physician. However, the CA role is non-regulated in Ontario, meaning ITPs in these roles may be left doing administrative or janitorial tasks. Manitoba, Alberta and Nova Scotia have regulated the CA role. In those provinces, ITPs are eligible for a defined type of licence and have a clear scope of practice as CAs. Even better would be for these roles to serve as a bridge to independent licensure by providing opportunities for ITPs to retain their recency of independent practice, which is a requirement for physician licensing in all provinces. Provincial regulators have a clear role to play, like introducing new classes of registration that align with best practices in other Canadian jurisdictions.

Taken together, these measures have the potential to rapidly increase the physician-to-population ratio and the number of physician-extenders throughout Ontario Investing in these measures could yield:

1. More equity in health-care delivery by diversifying the supply of qualified physicians and enabling more access to culturally appropriate care.
2. Improvements to patient health and wellbeing through increased access to health services and reduced wait times for primary and secondary care.
3. Better use of human resources with an increased supply in health-care professionals, reducing strain on current providers and lowering the risk of burnout and turnover.
4. Better use of medical skills by allowing ITPs to pursue the most appropriate pathway to licensure and enabling them to practice sooner.
5. Cost savings by more efficiently assessing and licensing qualified ITPs; a 2007 study showed that investments in competency-based assessments that lead to professional registration of ITPs in Canada (such as PRA) can generate rates of return between 9 per cent and 13 per cent by streamlining professional re-entry.

From a social justice and anti-discrimination perspective, all individuals should have equitable opportunities to have their training and experience assessed and rewarded in skills-commensurate employment. This principle is outlined in the Lisbon Recognition Convention, to which Canada is a signatory.

Spending on health care already makes up about 12 per cent of Canada’s GDP and continues to rise while at the same time access to care is in decline. Investing in measures that can effectively harness and support human capital can provide sustainable returns in the short and long term.

The issue of physician supply also sits in the broader context of health systems transformation in Canada. Shifting models of care delivery, adapted scopes of practice, restructuring of compensation models and the growth of physician-extender and nurse practitioner roles will all continue to impact the availability and quality of care being provided.

In this context, there is an opportunity for stakeholders in Ontario to think strategically and creatively about how licensing pathways for internationally trained health care professionals can and should be structured. The urgency of the health-care crisis demands that we look beyond historical precedents and the status quo toward what may be possible within the system. Collaboration between all involved stakeholders, including ITPs, is needed to design solutions that are effective, equitable and sustainable.