What are we doing about Canada’s health human resource crisis?

Canada is facing a serious health human resource crisis in many professions, profoundly affecting nursing and medicine. The Canadian Nursing Association estimates a shortage of 60,000 nurses alone. While it is difficult to quantify the shortage of doctors, Canadian Medical Association data shows that Canada has 2.7 physicians per 1,000 population (including residents) compared to the Organization for Economic Co-operation and Development average of 3.5, meaning that Canada’s physician to population ratio ranks 29th out of 36 nations. 

In medicine, the largest gaps are in primary care, with an estimated 20 per cent of Canadians unable to find a family physician, but shortages and maldistribution of specialists is also a serious problem. From community clinics to hospitals, health care professionals in Canada are experiencing high levels of burnout exacerbated by shortages and urgent attention is required.  

Small pool of Canadian physicians, big training hurdles for international medical graduates 

The reasons for physician shortages are multifold, including a history of training fewer Canadian physicians than the population requires, high hurdles for international medical graduates (IMGs) to access training, credentialling and licensure, and a lack of mobility of physicians across Canada. Furthermore, data suggests that with increased administrative burden in practice, greater complexity of care, and inconsistent development of integrated, team-based care models, individual physicians are unable to care for the same number of patients as they could in the past. 

Each of these problems requires different solutions. For example, three new medical schools are in development in Canada and many provinces are increasing the number of residency training positions. Although these steps will add new doctors in coming years, the long training cycle to complete medical school and residency means that this cannot be the only solution. 

Expanding, accelerating pathways to the Canadian system

A quarter of physicians practising in Canada today received their medical degrees outside of Canada and this proportion has been stable for more than a decade. But data from the Medical Council of Canada shows that of the 1,700 IMGs who passed their exams last year, less than half of them found a way to enter the Canadian system. The Royal College is working closely with Medical Regulatory Authorities – the provincial and territorial colleges that provide licensure for physicians – as well as Health Canada, to address this situation. 

We have three main pathways for IMGs, all of which are being modified or expanded. 

  1. The Practice Eligibility Route (PER) is for candidates who have trained in a substantially equivalent program outside of Canada, are certified in their home jurisdiction and who complete five years in practice as well as the Royal College exam. The PER has seen a significant increase in applicants gaining examination eligibility, from approximately 100 per year pre-pandemic to 350 per year now. 

  2. The Jurisdictional Route is for candidates from any one of 29 certification organizations around the world who applied for recognition during the open call period from 2000-2005. Certificants from these approved jurisdictions can apply to write Royal College exams and do not require a practice period to become certified once successful. The Jurisdictional Route results in approximately 200 candidates per year achieving exam eligibility. Ensuring appropriate diversity within this route has been a challenge and in 2018, Royal College Council recommended its discontinuation. However, the current situation has necessitated maintenance of this route and reinvigorated interest in finding ways to expand the breadth of and diversity of jurisdictions recognized.

  3. The Practice Ready Assessment Route (PRA) is for candidates who complete a substantially equivalent program, are certified in their home jurisdiction and who have been given a licence to practise in Canada by a Canadian Medical Regulatory Authority. Formalized PRA programs have been in operation for several years in Internal Medicine and Psychiatry but not all regulators participate in these programs. The Royal College is working in earnest to expand the specialties and nomination criteria for PRA and I will share more details on this work in a future column.

Finally, across all pathways we have decreased the processing time for most applicants from an average of 6-18 months to 4-12 weeks. I am grateful to the Royal College staff for their incredibly hard work to reach this standard.

The Royal College is very concerned with Canada’s shortage of specialist physicians and we will continue to explore new ways to accelerate and evolve our pathways and processes. I look forward to sharing more on our progress in a future column. 

Brian Hodges is the 47th President of the Royal College of Physicians and Surgeons of Canada. He is the executive vice-president of education and chief medical officer at the University Health Network. A professor in the University of Toronto’s Temerty Faculty of Medicine and at the Dalla Lana School of Public Health, as well as a senior fellow at Massey College, Dr. Hodges is also a practising psychiatrist.