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.

Recommendation #1: Assess All IMGs

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.

Recommendation #2: Help IMGs Become Familiar with Ontario Practice Settings and Procedures

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.

Recommendation #3: Develop Web-based Legal and Ethical Training Tools for IMGs

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.

Recommendation #4: Increase Postgraduate Training Positions

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.

Recommendation #5: Facilitate Movement Between Fields of Practice

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.

Recommendation #6: Recognition/equivalency of Screening Examinations

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.

Recommendation #7: Allow for Registration of Physicians in Practice Outside of Ontario Who have met Ontario’s Standards in the Past

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.

Recommendation #8: Develop a Process to Recognize Specialists

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.

Recommendation #9: Develop a Process to Register Specialists Recruited to Practice in Academic Health Sciences centers

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.

Recommendation #10: Allow for Restricted Registration for Residents

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. The Physician Resources Task Force has recommended that residents be permitted to work, for pay, outside their training requirement.

The College notes it is crucial that neither patient care nor the education of the residents be compromised. In order to protect these interests while tapping this potential resource, the College proposes that a two-year pilot project be undertaken to permit resident moonlighting under limited conditions.

Recommendation #11: Consider Developing and Implementing a Physician Assistant Program

a) The government of Ontario should facilitate liability insurance funding for physician assistants.

Based on the recommendations of the Physician Resources Task Force, a pilot project was funded to allow international medical graduates to qualify and work as physician assistants in supervised practice settings. This had the benefit of increasing the human resources available to health care delivery, as well as giving IMGs experience in Ontario health care settings that might ultimately assist them in meeting criteria to gain certificates of registration to practice medicine independently.

To qualify as a physician assistant, a candidate would be required to hold a degree in medicine, to have completed the Medical Council of Canada Qualifying Examination, and to receive an objective assessment in an academic environment.

When an attempt was made to implement the project, it was found that liability insurance was not available for this group. As a consequence, the institutions prepared to accept physician assistants could not do so. Liability insurance is an absolute necessity for participation of physician assistants in our health care system.

The College recommends that the government ensure liability insurance is made available for these positions.

b) In the long term, the College should consider creating a registration category for physician assistants.

If the pilot program is successful and a consensus can be achieved with respect to a defined scope of practice, training programs and stable funding, the College should consider creating a category of registration for physician assistants.

The 1990s serve as a powerful reminder of the importance of being able to reasonably forecast physician numbers. In approximately 10 years we went from a projected physician surplus to a physician shortage. We believe that new tools are necessary to monitor the physician human resource situation, as well as that of other health professionals, to ensure that future needs can be met.

Recommendation #12: Create a Health Human Resources Planning Body

The College recommends that the Minister of Health should immediately establish and appoint a Health Human Resource Planning body.

With the benefit of a strategic forecast of physician human resource needs, government, universities and the health care profession licensing bodies will all be in a better position to ensure that we have the facilities and resources to educate, assess and register health care professionals in the future.

Recommendation #13: Establish the Goal of Sustainability of Physician Resources in Ontario

The province should establish a goal of sustainability of physician human resources.

To ensure Ontario has an appropriate supply of physicians, planning for an infrastructure must take into account those who will be educated in Ontario and those who will choose to move to Ontario from another province, immigrate or return to Ontario from the country of their training. The processes must be equivalent for all physicians. There should be an assessment of, and sufficient funds for, training positions from all streams, including an increase in the number of positions in medical schools as well as an increase in the capacity to evaluate those trained elsewhere.

In addition to considering the number of individuals entering the practice of medicine in Ontario, the infrastructure planning process needs to take into account those physicians who will leave the practice of medicine altogether and those who choose to leave Ontario to practice elsewhere.

Recommendation #14: Link Training Positions to Physician Resource Needs

The Health Human Resources Planning body should take, as one of its priorities, a strategic approach to the funding allocation among specialties for training positions.

One of the problems facing Ontario health care today is the balance of physicians choosing one area of practice over another area of practice. Much of the attention is focused on the shortage of family physicians, but some specialty fields are also in a crisis situation and projections suggest serious under-representation of other specialties is expected in the near future.

Rather than addressing these problems of resource allocation by shifting the number of training positions available at any given time, the College recommends that the Health Human Resources Planning body analyze the needs of the health care system over the long term and come up with a rational, multidimensional basis for the allocation of training positions.

Recommendation #15: Evaluate Alternative Delivery of Care Models

Alternative care model delivery also should be evaluated.

We recognize we may never be able to replenish the physician complement to levels previously enjoyed. More importantly, the College of Physicians and Surgeons of Ontario recognizes our health care system is changing to the degree that delivery of care no longer takes place through exclusive individual domains of practice but through multidisciplinary teams. Accordingly, we need to address delivery of care from the perspective of access to health care for patients in a multi-disciplinary environment, rather than just by physicians.

The College is prepared to evaluate and change its regulatory framework to ensure regulation methods of the past are not standing in the way of new and better modes of health care delivery.

Finally, the College urges government to consider that, due to changing practice patterns, the provision of primary health care may incorporate providers in addition to family physicians or general practitioners. Planning for future physician human resource needs must take into account the degrees to which specialists, like pediatricians or internal medicine specialists, provide primary care.

Solutions to the physician supply problem are complex and require the commitment and cooperation of a number of key players in the health care system. The College is ready to do its part and challenges the government of Ontario and its other partners in the enterprise of doctor resource management to do the same.

The government should take immediate steps to provide assessment and training opportunities for eligible international medical graduates. Clearly other stakeholders, including the College, have important roles to play here as well. We pledge to do our part to ensure that our processes are transparent and responsive.

Tackling the physician resource challenge is a top priority of the College. Beginning in 1998, the College began working with the Council of Ontario Faculties of Medicine (COFM) to find ways of assessing and training international medical graduates (IMGs) so that they could practice in Ontario.

The result of this collaboration was development of an Assessment Program for International Medical Graduates (APIMG) and a process for academic registration under which qualified candidates who would not otherwise be eligible for a certificate of registration are permitted to work in academic centers in medical education and research.

Since May 2002, 82 candidates have been accepted into the APIMG program. Thirty of these have successfully completed their assessments and are now in practice in Ontario communities. Fifty-two are still in the assessment or training phase of the program.

Between Feb. 2002 and Dec. 31, 2003, the College approved 100 applications for academic registration. As a result of this program, 182 physicians are now practicing or will be soon. In total, approximately 800 IMGs have begun practicing medicine in Ontario during the past five years.

The College Council identified the physician resource issue as a top priority and goal in its strategic plan. In pursuit of this goal, the College facilitated the creation of the Physician Resources Task Force.

The Physician Resources Task Force is comprised of representatives from the Ministry of Health and Long Term Care (MOHLTC), Council of Ontario Faculties of Medicine (COFM), Ontario Medical Association (OMA) and the CPSO. The Task Force has heard presentations from the College of Family Physicians of Canada, the Royal College of Physicians and Surgeons of Canada, the Professional Association of Internes and Residents of Ontario, the National Task Force on IMG Licensure, and the Association of International Physicians and Surgeons of Ontario.

In 2002, the Task Force produced 15 recommendations aimed at reducing barriers to the recruitment, registration, education and training of physicians in Ontario. The government of Ontario has publicly supported eight of the Task Force’s recommendations.

Following is a summary of action that has been taken to date to implement the recommendations of the Task Force:

  • A clearinghouse has been created to assist physician applicants through the registration, credentialing and assessment process;

  • The number of postgraduate training programs has increased, allowing some qualified candidates access where positions were previously unavailable;

  • The government of Ontario has increased funding for educational and infrastructure capacity to support the increase in the number of training positions that have been approved (medical school enrollment increase);

  • The College has established an assessment and quality assurance program to provide accelerated registration for physicians who are currently in practice in other jurisdictions and wish to practice in Ontario;

  • The College has established a policy to recognize non-family medicine specialists who have met critical educational and practical criteria but have not received the Royal College of Physician and Surgeon’s specialist designation.

The Physician Resources Task Force continues to develop workable solutions to the physician resource challenge. The task force is also helping to implement initiatives that have been announced by government.

“Tackling the Doctor Shortage” originally appeared in the May/June 2004 issue of Members’ Dialogue, published by The College of Physicians & Surgeons of Ontario.

Author notes

The College of Physicians & Surgeons of Ontario