Since 1998, the Welland Multicultural Centre, the Employment Help Centre in St Catherine’s, the Council of Agencies Serving South Asians, South Asian Family Support Services, Windsor Women Working With Immigrant Women and the Kitchener-Waterloo Multicultural Centre have been working individually and collectively with foreign trained physicians. The six agencies have worked closely to form an Ontario-wide coalition in support of foreign trained doctors. Currently, over 170 foreign trained physicians are registered with our agencies.

The work of these agencies has involved ongoing consultation with our membership and various research initiatives which have included a detailed review of the licensing requirements for foreign trained doctors in each province. Based on this work, the following is a step by step review of some of the barriers that prevent foreign trained doctors from being integrated into the Ontario healthcare system. The recommendations made under each section are intended to be short term solutions to address the current doctor shortage and objectives of this task force. Although some recommendations are not directly related to these objectives, they are relevant to procedural changes and therefore included.

We strongly believe that the direct placement of foreign trained doctors in the health care system, upon successful completion of the MCCEE, is an expedient and cost-efficient solution to the current crisis in Ontario.
 

1. MEDICAL COUNCIL OF CANADA EVALUATING EXAM

There is agreement in principle on the importance of testing general medical knowledge and ensuring that a national standard of knowledge and competence is met or exceeded.

The MCCEE establishes that candidates have comprehensive understanding of general medical knowledge. The exam is only available to candidates whose educational credentials qualify under the World Directory of Medical Schools published by the World Health Organization, and have been evaluated by the MCC. However, successful completion of the exam does not systematically confer recognition of equivalence to educational completion within the Canadian system, nor does it grant an educational license to commence appropriate practice with corresponding remuneration.

The current fee for the MCCEE is $1000. This fee is prohibitive for many candidates. Further, the time required to prepare for this exam is significant and impacts on an individual’s earning capacity during this period. Candidates for professional licensing are not eligible for OSAP or other existing student loan programmes. Consequently, many candidates abandon the process because of financial limitations. Successful completion of the MCCEE remains valid for five years, after which candidates must re-sit the exam at the same cost. There is no evaluation of individual activity or level of involvement in the medical profession during the period to establish how current the candidate’s knowledge base is. As well, there is contradictory recognition between the Medical Council of Canada and the College of Physicians and Surgeons of Ontario, with the latter accepting the pass after five years.

1. Grant candidates who have passed the MCCEE automatic and immediate eligibility for residency, under the normal supervisory and remuneration structures in place.
2. Review cost of exam and determine validity of current level of charge.
3. Establish government sponsored loans board to cover the costs of the exam and additional living expenses during the period of preparation (up to 12 months).
4. Eliminate the current policy of automatic expiry after five years.
5. Ongoing professional development / education should be accessible to all candidates who have successfully passed the MCCEE.

The process of verifying competence in written and spoken English is through the TOEFL exam which costs $110 US and the TSE exam which costs $125 US. The current policy in Ontario only recognizes the successful completion of these exams for two years, after which candidates must re-sit the exams at the same cost. It is redundant to re-test language skills when an individual has already passed the exam and has since been living, studying and working in Canada. In addition, there exist cases where individuals who have not been educated at English universities but who are native speakers, or who have worked professionally in English, are required to sit these exams.

1. Eliminate expiry policies related to the TOEFL and TSE exams so that successful completion of one set of the exams is sufficient proof of English competence.
2. Establish an exemption process whereby candidates may present evidence of professional experience in English and/or native competence and be exempt from this requirement.

The IMG exam is offered only once per year. Ontario is the only province that requires candidates to complete this exam. The content and structure of the exam is comparable to the MCC Qualifying Exam Part I. Given the redundancy of administering this exam, the purpose historically has been to restrict access of foreign trained doctors to the Ontario health care system. Regardless of the number of candidates who successfully pass the exam, only 72 candidates are permitted to move on to the next step which is the Objective Structure exam, an oral examination which subsequently admits only 24 candidates to the Pre-residency program. These exams in their entirety serve only as an elimination process and add no value to the evaluative process.

1. Eliminate both the International Medical Graduate exam and the Objective Structure exam.

The current pre-residency program is closely identified with the internship required of Canadian medical school graduates. There are however two significant differences: first, foreign trained doctors are required to pay $1400 in order to participate in the program and Canadian medical students receive remuneration for their services; and second, Canadian students are guaranteed a position, while only 24 foreign trained doctors have access each year. This number was derived several years ago, and has remained constant.

The internship concept itself implies a practice period for the application of learned skills. For a fully trained physician, this requirement is redundant, and not part of a clearly defined evaluative process. What foreign trained physicians and surgeons require instead, is a concise professional orientation. While the internship period does also provide an evaluative component, and given the fact that fully trained and experienced physicians should only be expected to demonstrate competence, a more efficient evaluative tool (e.g. applied clinical examination comparable to US system) could replace this current practice.

1. Eliminate the pre-residency programme in its current form, and eliminate the absolute number of positions made available to foreign trained doctors.
2. Establish equal access for foreign trained doctors and Canadian trained doctors as per the recommendations of the ACCESS report of the Ontario Ministry of Citizenship, Culture and Recreation, 1989. Minimally, if an annual quota is required to regulate numbers within the profession, then a formula should be derived based on relevant criteria, principles of equity and diversity, and should be reflective of the current doctor shortage.
3. Replace the pre-residency and residency programmes with a professional orientation and clinical evaluation process.
4. Implement a model of clinical evaluation that is built on the premise that the foreign trained doctor has sufficient practical experience and where the objective is focused on establishing equivalence and meeting national standards.

The current practice of directly recruiting specialists and family physicians from overseas is neither cost effective for the Canadian taxpayer, nor efficient use of the ready and able human resource already in Canada. Allowing doctors who have been directly recruited to fast track through the system for the sake of expedience in resolving the current crisis endangers the public safety that the entire system was designed to protect. Given the legislative responsibility of the professional licensing body to protect the public, adherence to the established system is imperative. Finally, there is no apparent transparency of this current process and therefore it becomes subject to questions of procedural equity and fairness.

1. Suspend overseas recruitment until a reliable assessment of current human resources has been completed and foreign trained doctors in Canada are given first opportunity to fill available positions.

As the federal Ministry of Citizenship and Immigration enlarges its objectives for the coming year, and 500,000 newcomers are expected to arrive in Canada, the need for medical service delivery in ethno-specific communities can be expected to grow significantly. This new development is subsequent to the current recognition of a crisis in the health care system in Ontario, and further emphasizes the critical need to process and employ the current reserve of foreign trained doctors in Ontario. As Canada continues to rely on significant level of immigration to sustain the economy and demographic balance, it is critical that the Ontario Ministry of Health and the various licensing and regulating bodies respond to the emergent needs of the community. This response must include a careful review of the explicit need for diversity in Ontario medical practice.