At a time of crisis in the healthcare system it is easy to criticize – it is not as easy to find the correct solutions for this complex problem.
The College is acutely aware of the shortage of physicians in our Saskatchewan healthcare system. We recognize it is a worldwide issue and not limited to Saskatchewan or Canada. We are all competing for the same pool of talent. We are in daily contact with physicians and are aware of the heavy workloads and see the consequences of stress and burnout.
Standards for licensure are like standards for the clinical practice of medicine. They may change in response to newer information. The speed of the change however is different. The standards for clinical medicine are evidence-based and change quickly. Legislation and bylaws govern the regulation of medicine and require time to change.
Health is a provincial matter and therefore the regulation of medicine is a provincial matter. Licensure in this province is set out in our regulatory bylaws, unlike for other Medical Regulatory Authorities (MRAs) where it is determined by Committee and policy. Our regulatory bylaws require government approval after stakeholder input. Council delegates licensure decisions to the Registrar. As the Registrar, I must apply the bylaws as fairly and consistently as is possible.
Over the last 10-15 years the College has collaborated with its sister medical regulatory authorities to achieve a national standard that sets the criterion for an unrestricted full/regular licence or for a provisional licence. This served to reduce the categories from 128 forms of licensure to four categories. This standardization was important to ensure that mobility through the Canadian Free Trade Agreement relies on the same standards for licensure in each province. What is currently happening across Canada in varying degrees is that medical regulatory authorities are responding to direction from their governments on who to license. Several provinces are instituting legislative changes that enable government officials to determine who will be licensed, while other provincial regulators are being asked to do “work arounds” through policy changes which deviate from the national standards. The effect is the same – the criterion for licensure is not applied evenly or consistently across Canada, therefore eroding national standards.
There are some who have proposed national licensure as a solution for our current challenges. There are a number of challenges if governments want there to be national licensure. The first is that there should not be national licensure without national standards for licensure. Even if it were constitutionally possible to have national licensure, it might make it easier for some patients to access care; however, it will be at the expense of other patients’ access. National licensure may allow providers to respond to an access issue momentarily, but it does not increase overall capacity as there are limited numbers of providers. As one of my colleagues states, “It’s like rearranging the chairs on the Titanic” and hoping for a better outcome.
Contrary to what you may hear in the media, the CPSS has been and continues to be flexible in its approach to licensure. We are monitoring what other MRAs are doing and considering whether we think it is appropriate to do the same. As a matter of urgency, I have requested that the Federation of Medical Regulatory Authorities of Canada (FMRAC) conduct an ongoing survey to serve as a fluid registry of the “work arounds” utilized in other provinces. Such a registry would serve to increase transparency and allow us to question whether our current standards are the correct ones. Unfortunately, this work has not yet come to fruition.
We are collaboratively working with our government to find ways to add capacity to our system by considering maximizing scopes of practice of other providers, adding new categories of providers, and supporting those currently working in the system as best we can while we wait for others to join.
We hear that the Medical Council of Canada Qualifying Examination I (MCCQE I) is a barrier. It is an examination at the level of exit from medical school and entry into residency. At present, it is a minimal standard for licensure for physicians regardless of where they obtained their medical education (unless they have passed American licensing exams acceptable to Council). We are currently monitoring what other provinces are doing; several provinces have relaxed the requirement for those who hold certification in a specialty. The Registration committee and Council will continue to consider options.
Demonstrating English proficiency through English language examinations for licensure is thought by some to be a barrier. It is essential that healthcare workers, including physicians, are able to communicate effectively with patients and other healthcare workers.
We have accepted two additional tests of English language proficiency that are available on online, to add to the one we currently use. While I cannot waive the requirement, I can substitute alternate means of proving the candidate’s ability to communicate in English, such as successful completion of Canadian high school English, secondary training in an English-speaking country (considering accepting secondary as well as primary training), successful completion of Canadian examinations in English, and practising medicine in English. We are working to change the list of accepted English-speaking countries by our national organization FMRAC, which currently restricts English-speaking countries to primary education rather than secondary education.
The main way a physician can achieve a full unrestricted licence in Saskatchewan is to meet the minimum criteria of training, good character, etc. as well as the LMCC (MCCQE I), and specialty certification. Those who cannot achieve the criteria for full licensure may receive a provisional licence contingent on meeting minimal requirements. We have a summative assessment process as an alternative to Canadian certification exams to achieve enduring licensure for those specialists who have foreign training. Foreign-trained family physicians may enter the SIPPA process and, if successful, may achieve a provisional licence and complete a summative assessment after a minimum time in supervised practice for enduring licensure. If they have achieved their certification examination, they will not be required to complete a summative assessment.
At the last Council meeting, Council determined it would consider a process to assist Canadian-trained physicians who have lost eligibility for their certification examinations. This aligns with what other provinces are doing. A prelicensure assessment is an underutilized process for the Saskatchewan Health Authority (SHA) to use to assess foreign trained specialists who are not eligible for the RCPSC certification process. This involves a 12-week assessment on an educational licence, and if successful, they achieve a provisional licence to work independently, while working towards the requirements to achieve an enduring form of licensure through summative assessment.
As Council and staff work with others to finds ways to increase capacity of physicians in the system, we ask that you be willing to assist in assessment and/or supervision, so that these additional physicians integrate successfully into practice, to join you in the provision of safe care..