Dr. Viren Naik
Chief Assessment Officer, Medical Council of Canada
Canada’s physician workforce depends on international medical graduates. An alternative route to licensure is helping more of them enter practice each year.
Canada depends on international medical graduates (IMGs), particularly in family medicine and particularly in rural and remote communities. IMGs comprise an average of 25 per cent of the physician workforce across the country. In Saskatchewan and Newfoundland, that number is 50 per cent and 40 per cent, while in rural Saskatchewan, that number jumps to 70 per cent.
In today’s context of a health-care system under strain, and with many in Canada lacking access to a family physician, the Practice-Ready Assessment (PRA) is one route that can help alleviate those health human resource challenges. Seven provinces in Canada participate in a PRA framework called the National Assessment Collaboration (NAC), overseen by the Medical Council of Canada (MCC).
NAC PRA is an alternative pathway to licensure for IMGs who have completed residencies and practised independently outside Canada. For 12 weeks, under the supervision of trained physician assessors, PRA candidates’ skills are observed and assessed in real-clinical settings for readiness to practise within Canada. After completion of the rigorous assessment, successful candidates obtain provisional licensure, and most are fully licensed within two years. Dr. Jack Burak, Clinical Director of PRA-BC, says, “if they pass our robust assessment, we have total confidence that they will practice safely and confidently. And if they decide to move across the country once they have their full license, the medical regulatory authority in whatever jurisdiction they move to will have that same comfort.”
NAC PRA outlines a set of common standards for assessing IMGs. Clinical Director of Nova Scotia’s Practice Ready Assessment Program (NSPRAP), Dr. Fiona Bergin, established her program using the national framework and drawing on the existing provincial programs, which, she explains, “are collaborative and helpful to each other, sharing both expertise and information.” The provincial programs rely on the MCC’s examinations to identify qualified candidates and use MCC- and NAC-developed common tools, resources, and assessor training. One of these resources is the Communication and Cultural Competence orientation program housed on physiciansapply.ca, a self-education program intended to help physicians learn about the cultural expectations and standards of communication between physicians and patients and between health professionals in Canada. The latest module added to the program is “Compassionate Virtual Care.”
But why is PRA necessary? The common conditions physicians see in Canada are often related to an aging population, chronic diseases, and the country’s unique population groups, including Indigenous Peoples, and might not reflect the common conditions seen in an IMG’s home country. Dr. Jon Witt, Medical Director of the Saskatchewan International Physician Practice Assessment (SIPPA), explains that there’s a bridging of knowledge and skills that needs to happen to support an IMG’s transition into Canadian practice and ensure patient safety. “During the 12-week clinical field assessment, assessment is going on, but learning is also going on. A broken ankle is the same across the world, but how you investigate it, how you communicate to patients, what follow-up would be done, how you communicate to other members of the team, and the medications you would use. Those are different.” It’s essential that PRA candidates demonstrate knowledge of appropriate therapeutic strategies when managing medical conditions in a Canadian context while meeting patients’ expectations of a high standard of care. Importantly, as Dr. Burak clarifies, PRAs are “not re-training.” PRA programs identify qualified candidates and discover through assessment whether they’re competent and safe to practise in the Canadian context.
A shared challenge of the PRA programs is the recruitment of assessors. It’s also the single most limiting factor in expanding PRA program participant numbers. A lot of demands have been placed on physicians during the pandemic; the same diminishing pool of physicians is caring for patients while acting as teachers and supervisors to medical learners in the Canadian streams. Often, it’s other IMGs who step up. Dr. Witt says, “they understand the immigration journey. A lot of them have trained in the same country, sometimes even the same medical school as the applicants coming through.” Many assessors have come through PRAs themselves and see becoming an assessor as a way to give back. Dr. Bergin adds, “there’s a real feeling of kinship.”
At the end of each 12-week intake, new family physicians enter practice, joining communities where they’re desperately needed. Dr. Bergin hears frequent praise for the PRA candidates from both assessors and patients. “They’re being well received in their communities and are doing well out there.” NAC PRA assisted 600 family doctors in entering the Canadian health workforce in the last five years. Averaging 120 doctors annually, this figure is comparable to the number of graduates from a Canadian medical school.
In good news, existing NAC PRA programs have recommitted to the framework for another three to five years. Dr. Burak believes “if the IMG pool of applicants is large enough, there should be the potential to expand all of the programs across the country.” NAC PRA is making a notable contribution to the physician workforce and offers an essential bridge to IMGs to follow their calling in Canada.