Health Committee on April 1st, 2010

[The Chair, Conservative, Joy Smith]

Good morning, everybody.

I notice that we're a little past nine o'clock, so we definitely should start now.

Pursuant to Standing Order 108(2), we are doing our study on health human resources.

Today I'm very pleased that we have, from the Alberta International Medical Graduates Association, Ali Varastehpour, vice-president, and Chander Hariramani, treasurer. It's very nice to have you here. Welcome.

From the Canadian Resident Matching Service we have Jim Boone, general manager and chief executive officer. And from the Federation of Medical Regulatory Authorities of Canada we have Fleur-Ange Lefebvre, executive director and chief executive officer of that association.

We also have with us, from J.A. Hildes Northern Medical Unit, Dr. Bruce Martin, from the faculty of medicine, University of Manitoba. That's one I'm very familiar with, Dr. Martin. I hear quite a bit about you, because my own daughter wants to go into medicine.

And from the Medical Council of Canada we have Dr. Ian Bowmer, executive director and chief executive officer. We are so pleased to have you here.

We're going to have five-minute presentations from each of the organizations, and following that we'll go into our questions and answers.

We will begin with the Alberta International Medical Graduates Association, Mr. Ali Varastehpour.

[Dr. Ali Varastehpour, Vice-President, Edmonton, Alberta International Medical Graduates Association]

We would like to begin by expressing our sincere gratitude to the members of the Standing Committee on Health for inviting us to Ottawa today.

The issues related to skilful immigrants coming to Canada in general, and physicians in particular, are evolving from a domestic issue into an international one. I would like to draw your kind attention to the report recently released by the UN expert on minority affairs. I have a copy of this report here for members of the committee to review.

I would like to read item number seven directly from this report, as it is particularly relevant to our present discussion. I will leave a copy of this with the clerk later on.

Item number seven, issued by Gay McDougall, says:

There is a deep level of frustration among minority communities that highly qualified and skilled workers have been encouraged to migrate to Canada, only to find on their arrival that their qualifications are not recognized at the provincial level. They are unable to gain employment in their former professions despite critical shortages, including of doctors and nurses in some regions. I was told of numerous cases of professionals who described being recruited when practising their professions in their home countries but have faced lengthy, expensive, and unexpected hurdles to satisfy the credentialing requirements in the various provinces in Canada. Meanwhile they are forced to resort to take on low skilled, low waged, precarious employment for years. For some, the difficulties experienced have led to their living in conditions of hardship and poverty. The cliché of ‘doctors driving taxi cabs’ resonates as reality for many minority professionals in Canada.

Right now, regulatory bodies apply different rules to different physicians. While their discretionary power is important, it is equally important to note that their inconsistent actions are costing Canada on the international stage, and are affecting our goals and aspirations.

Presently the Medical Council of Canada administers three exams: evaluating exam, or EE, qualifying exam 1, and qualifying exam 2. The first one, the evaluating exam, is applied at an increasing cost to foreign graduates only. We speculate that this exam is similar to the old ESFMG, in that it was composed of questions that normal Canadian students find hard to answer. It serves as a source of income to the MCC and a hurdle for foreign graduates. Widespread objections in the United States were partly responsible when they switched to a new unified exam for both American and foreign grads. They switched in the past few years.

So far, we have been successful in passing these exams, mostly through our own sweat and blood and effort. This does not mean we reached the level set by MCC, however. We have indeed surpassed it. MCC favours Canadian students by repeating question items under exams. It is a well-known fact that Canadian medical schools collect and indeed answer these questions and circulate them amongst their own. Thus, when we pass the exam, we feel a great sense of pleasure competing, and beating Canadian students in their own home field.

We believe there are huge deficiencies in the undergraduate Canadian medical education system, but we won't spend any time on that, as it is not the focus of our discussion today.

Parallel to the above-mentioned exams and their associated costs, you might be surprised to know that post-graduate physicians come to this country every day to pursue their graduate medical training, based only on passing the evaluating examination in their home country. Program directors fill their spots by recruiting these students, who are willing to work for free. In turn, department chairs require them to take no more exams but the evaluating exam and pass it at any score and any number of times.

Yes, ladies and gentlemen, money talks here, and people have been buying their way into the Canadian medical system openly and legally for a long, long time.

In my humble opinion, this practice is not only unethical, it is purely illegal. In fact, if we had sufficient funds or faith in the Canadian justice system, we would have challenged the regulatory bodies and all academic hospitals in this country for monetary and emotional damages inflicted upon so many families.

Honourable members of the House, I'm not here to ask for preferential treatment; I'm simply asking that the same rules are applied to us. This requires funding of the residency programs through legislative efforts.

This year over 300 positions were left unfilled all across Canada. I suspect that there would have been a lot more positions available today if so-called visa students were kept out of the system.

I'm not aware if any other country has ever pursued this shameful model. No one can deny that Canada is training more doctors for other countries than it does for its own.

The dilemma surrounding postgraduate medical study does not stop here. If you have a cursory look at the website of the University of Alberta Hospital, you would find academic...[Inaudible—Editor]...with no real college designation, some with only an evaluating exam under their belts, and some even have doubtful residency training even in their own home countries. Yet they have been licensed to practise medicine in Alberta.

Honourable members of the House, I am here to tell you that Canada has a pool of qualified physicians willing to work all over Canada. We are proud to see ourselves as Canadians in a few years. Our Canadian dream has been freedom, democracy, and achieving excellence in our profession. Unfortunately, regulatory bodies are acting beyond their duties and functioning more like gatekeepers for class and prestige, and this must stop. We will continue to struggle until race, religion, and accent play no role in getting medical licensure.

We are puzzled as to why Immigration Canada brings to this country over 200,000 people a year when doctors cannot do doctoring, and carpenters, plumbers, and gardeners cannot follow their passions in Canada. Perhaps Immigration Canada should be converted to Colonization Canada, and they can use modern techniques of biology to clone human beings and place them wherever they want.

Finally, I would like to talk about sporadic good efforts in Alberta that can be extended to all over Canada. Alberta has the M-CA program, the mdical communication assessment program, which trains physicians in language skills and oral exams. Expansion of programs like M-CAP into a bridging program that would include clinical training would benefit us and Canada enormously. Again, it requires your political will and effort.

Wider introduction of limited registration would be another area where experienced, practice-ready physicians would be able to enter the workforce.

I thank you again for your attention. Please do not hesitate to contact me if I can be of any service to this committee. Thank you very much for your attention.

[The Chair, Conservative, Joy Smith]

Thank you very much.

Now we will go to our next presenter, who is from the Canadian Resident Matching Service. Jim Boone, please.

[Jim Boone, General Manager, Canadian Resident Matching Service]

Thank you.

Just one point of clarification: I'm not the CEO of CaRMS; I'm the general manager of CaRMS. I'm actually here pinch-hitting for Sandra Banner, who sends her regrets and was unfortunately unable to attend this meeting.

CaRMS is the gateway into post-graduate medical education in Canada. We hear on a daily basis the frustrations of international medical graduates and their concerns because we're an independent organization that sits on the fence between faculty and applicants for post-graduate training. So we do hear frustration, as Ali has expressed, from the thousands of IMGs across this land.

We've been matching eligible applicants to post-graduate medical training since 1970. This year is our fortieth anniversary. CaRMS has been serving the needs of IMGs and has been part of the system and in the matching process since day one, since 1970. The goal of our online electronic application service and matching service is to be completely transparent and accessible as a process. It's often misunderstood that CaRMS sets policies on recruitment. It's the Association of Faculties of Medicine of Canada, or AFMC, that sets these policies on how things are governed and how medical schools rank their applicants.

From 1994 until 2006 the AFMC only allowed Canadian medical graduates from their medical schools in the first iteration of our match. There are two iterations. The first fills as many vacancies as possible, and then leftover positions carry forward and there's a much shorter timeline for the second iteration. Up until 2006, only CMGs, or Canadian medical graduates, could participate in the first iteration. As of 2006, international medical graduates were also participating in the first iteration.

Since 2006, when the AFMC opened up their policy and allowed the schools to rank IMGs in the first iteration, most provincial Ministry of Health-funded positions for IMGs were in separate streams. Prior to 2006 CMGs were competing against IMGs for available positions in the second iteration. However, since 2006, when the IMGs were allowed in the first iteration of the match, most provinces have parallel streams. There are designated positions for IMGs in the first and second iteration of the matches, so Canadians are not competing with IMGs for these positions.

Since that time CaRMS has seen a dramatic increase in the number of IMGs participating in the match. In 2003 there were approximately 600 IMGs in our match. By 2007 the numbers had increased by more than 1,600, and have remained somewhat constant since that point; between 1,600 and 2,000 IMGs are participating in our annual residency year one match.

Since 2008 CaRMS has been the lead partner in an annual IMG information symposium. We recognize that IMGs are geographically dispersed. They don't have peers who are studying medicine with them, nor the ability to ask one another, as CMGs do, about what the match process is all about, what requirements are necessary regarding eligibility. So two years ago we organized the first annual international medical graduate symposium in Toronto.

We found that two-thirds of IMGs in this country are located within one hour of the greater Toronto area, which is very good for us to organize an annual event. Again, we had the Medical Council of Canada and Fleur-Ange's organization, FMRAC, involved, and about six or seven other organizations, including the Ministry of Health for Ontario, through HealthForceOntario. It's an opportunity for all our organizations to share information face to face with IMGs. Over 400 of them attend annually. But it's also a point for them to give us feedback, and the emotions are raw.

CaRMS also participated in the first annual IMG symposium held in Quebec this past year.

Early in this decade, CaRMS identified a subset of IMGs who were Canadians studying abroad, or as we refer to them, CSAs. They're defined as Canadian citizens or permanent residents who are studying medicine outside of Canada and in the U.S. Through a 2009-10 grant from Health Canada, CaRMS has been researching this group of Canadian students who elect to study medicine, and we've been studying them in more than 25 countries around the world.

I'll give you some statistics on international medical graduates. Our international medical graduate community includes CSAs or Canadians studying abroad. We do not differentiate between the two groups, so the CSAs are a subset of the IMG community.

CSAs represented 24% of the first-time IMGs participating in the match in 2008. In 2009 this number increased to 31% and in 2010 that number is now 40%. Again, we have approximately 1,600 to 2,000 IMGs participating in our annual match, and the number of matched IMGs in 2007 was 298, in 2008 it was 353, and in 2009 it was 392.

That's the end of my presentation.

[The Chair, Conservative, Joy Smith]

Thank you very much.

We'll now go to the Federation of Medical Regulatory Authorities of Canada, and Fleur-Ange Lefebvre.

[Dr. Fleur-Ange Lefebvre, Executive Director and Chief Executive Officer, Federation of Medical Regulatory Authorities of Canada]

Thank you very much, and thank you for the opportunity to represent some of the information we gave you on December 9 and to give you a bit of an update.

I'm presenting today on behalf of the Federation of Medical Regulatory Authorities and its 13 members, which are the provincial and territorial organizations. It was established by legislation to serve in the public's interest by setting standards of practice and professional conduct and determining the qualifications to obtain and maintain a licence to practise medicine.

In December you received a copy of the latest draft agreement on national standards for medical registration in Canada. A few things have changed since then, but it's still a draft and we're aiming to do a bit of approval at our AGM in June.

We have defined the Canadian standard as the set of academic qualifications that automatically makes an applicant eligible for full licensure in any Canadian province or territory. To achieve the Canadian standard, the applicant must have four things. The applicant must have a medical degree from a recognized medical school; we rely on two lists of Canadian and international schools. The applicant must be a licentiate of the Medical Council of Canada. The applicant must have satisfactorily completed a discipline-appropriate post-graduate training program and ensuing evaluation by a recognized authority. We haven't quite defined “recognized” for that, but we're working on it. Finally, the applicant must be certified by either the College of Family Physicians of Canada or the Royal College of Physicians and Surgeons of Canada. That is the Canadian standard.

On the topic of international medical graduates, the recently signed agreement among the regulatory authorities covers not only the Canadian standard but additional standards for recognition of international medical graduates seeking licensure in Canada. Medical regulatory authorities agree that IMGs who do not meet the Canadian standard may initially be eligible for provisional licensure.

Our work to develop the national standards for provisional licensure includes four areas of work. One is the eligibility criteria, or what gets you into the system to begin with. Two is the pre-licensure assessment. If that goes well, there are supervision requirements for the applicant or the licensee for the duration of that provisional licence. And finally, there is a formative assessment that will take the applicant from a provisional licence to a full licence.

This work is pivotal to our goal of meeting the requirements under chapter 7, which is labour mobility in the agreement on internal trade. It is ahead of the expectations stated about the medical profession in the pan-Canadian framework for the assessment and recognition of foreign qualifications.

We are working with the two national organizations that are responsible for the quality of family medicine and other specialist medical training in Canada. I mentioned them before. They are the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada. Both are doing what they can with their resources to determine the equivalency of medical training programs in other countries.

However, we know that we'll never have a complete picture of the equivalency, or even reasonable equivalency, of medical training around the world. Medical regulators in Canada will always have to rely on made-in-Canada assessments tailored to what is known about the quality of each international medical graduate. A tailored approach to assessments will be much more efficient than a one-size-fits-all approach, in our opinion. Although that might mean a faster track for graduates from some countries, we believe we can create a standardized approach that will be used across the country and that will be defensible both from the academic perspective and a human rights perspective.

The extensive experience and commitment of medical regulators in this country to foreign qualifications assessment and recognition is demonstrated by the licensing statistics in the table that was distributed today. We can get into this table later on, but you should have this before you--I translated it myself--and it will show you some numbers. We have asked our medical regulatory authorities to now start separating full and provisional licences for graduates of the Canadian system and international medical graduates.

You can do a bit of arithmetic and see that in some jurisdictions last year there were more international medical graduates who received new licences than graduates of the Canadian medical education system. We can talk about that a bit later.

This is a process in evolution, as we move to national standards. The way that people capture and upload the data to us will also be standardized.

Provincial and federal departments of labour and of health are very aware of the intensity with which medical regulatory authorities across Canada are developing a renewed national standard for physician registration, one that includes a common approach to the recognition and licensing of international medical graduates.

I can't repeat the next little bit enough: Medical regulatory authorities are tasked by governments in legislation to ensure physicians provide safe and effective care. They must walk a fine line between expectations for quality care and for access to any service at all in some parts of Canada.

Thank you for you attention. I will be pleased to answer questions in both official languages.

[The Chair, Conservative, Joy Smith]

Thank you very much.

We'll now go to Dr. Bruce Martin, who is with the J.A. Hildes Northern Medical Unit.

Dr. Martin, I understand that you're going to talk about not only the graduates, but as you couldn't make it to the last committee, you're going to talk about the remote areas as well—just to give us some insight into your expertise. Is that not correct?

[Dr. Bruce Martin, Doctor, Faculty of Medicine, University of Manitoba, J.A. Hildes Northern Medical Unit]

That is correct.

[The Chair, Conservative, Joy Smith]

Okay, thank you.

[Dr. Bruce Martin]

Thank you very much for having me here. I apologize for not being able to attend on Tuesday, when you were discussing issues of health human resources in rural and remote communities and their populations.

By way of personal introduction, I am a family physician. As a Canadian, I probably manifest some of the issues and attributes of individuals who've come through a system addressed to assist Canadians and other practitioners to work in remote northern communities. This was a significant part of my undergraduate medical education, part of my post-graduate medical education, and for more than 20 years I have served in remote populations, principally those of aboriginal ancestry in Canada.

By way of introduction of personal involvement, I'm with the University of Manitoba faculty of medicine. I have two roles there: I'm the associate dean of undergraduate medical education; and I'm also director of the university's J.A. Hildes Northern Medical Unit, a population and public health department initiative created in 1970 to address the underserved populations of northern Manitoba and what used to be the NWT, now the central region of Nunavut.

I have before me some speaking notes, which members have received, and would like to briefly introduce the challenges of health human resources in rural and remote populations.

[The Chair, Conservative, Joy Smith]

Dr. Martin, could I just interrupt you?

[Dr. Bruce Martin]

Sure you can.

[The Chair, Conservative, Joy Smith]

They have not received these, simply because they're not bilingual, but we'll make sure everyone gets a copy.

[Dr. Bruce Martin]

I apologize for that.

[The Chair, Conservative, Joy Smith]

That's okay.

[Dr. Bruce Martin]

I'd like to therefore address what I would refer to as an inextricable triad. When we look in northern remote populations we should be discussing not just health human resources but the contribution of the health care system, of the health system itself. I'll provide you some brief details. I will discuss disease and illness burden, and how that influences our ability to provide care, but the centre of that triad should be considered the patient and the community.

Regarding health human resources, the circumstances have been very well described historically and the current situation regarding health human resources has been unfortunately accurately predicted. I would reference very specifically the Royal Commission on Health Services, or Hall commission, in 1965, in which in volume two Justice Emmet Hall had a very lengthy subset of his commission and that of his commissioners regarding health human resources in northern populations.

This was followed on a number of occasions, but very explicitly by a report of Barer and Stoddart. Many of you are aware of the report of 1991, but they also did a report for a precursor of this committee in 1999 that looked at the determinants of health human resources and recruitment and retention for northern and remote populations. Both of those documents, and many others, predicted the deficit that we face. The deficit we face in health human resources now is not only absolute in numbers, but has very significant deficits in terms of the relative mix of health human resources and providers, and there is also a substantial deficit in skill set, which I'll return to.

The determinants of recruitment and retention are also very well and historically documented. There is a four-pillar approach to recruitment and retention that speaks to the personal interest of health providers and their background, their appropriate training, the attributes of communities in which they work, and the working conditions within those communities.

The solutions that we must have to address these deficits in health human resources are increasingly clear. They've been articulated before in fora such as this. There must be a clear emphasis on collaborative and inter- and intra-professional approaches to care. By that I mean working together, whether we're members of one profession or members of another profession. We must have innovative strategies in the undergraduate and postgraduate education of health professionals who wish to serve underserved populations, principally focusing on regulated health professionals.

There have been some creative strategies. There is a very innovative approach in the University of California, Los Angeles, called UCLA PRIME. There's another innovative approach that's been supported by your government and that of the provincial government in Manitoba called the Manitoba Northern and Remote Residency Program. We must also focus on the creation of a supportive competency-based and integrated community workforce. I'd be pleased to address questions in that regard.

Regarding the disease and illness burden, which I trust you spoke of or remarked upon in your previous meeting this week, it is clear that there are evolving patterns of illness in northern remote communities and they are profound determinants of a capable workforce. There are descriptions of the epidemiology, or the pattern of disease, and these unfortunately are following a predicted pattern of evolution.

We are seeing emerging new infectious diseases, but tragically we're also seeing a resurgence or a reawakening of previous infectious disease outbreaks. We're seeing chronic disease in numbers we have never seen before. We've seen increasingly social maladies in northern and remote communities, regardless of the ancestry of people of those communities, and those maladies embrace spiritual and mental health issues. They embrace issues of addictions. They embrace issues of self-harm and interpersonal violence.

Superimposed on the disease burdens are the broadest determinants of health, whether they be housing, employment, or education. Perhaps there's a genetic propensity to illness, but all of these impact communities and often intensify the disease issue, resulting in a profound illness burden, meaning the manner in which or the degree to which individuals face their disease.

The third component of the triad I discussed, or introduced, is inextricably bound to those first two: the health system. Quite tragically, the health system in northern remote settings is often and very accurately described as fragmented, under-resourced, and subject to jurisdictional complexity, ambiguity, and resultant neglect of populations.

There is clearly a need for aggressive so-called “system engineering”, a term that was first used in industry but is now extensively embraced in the Canadian and American health care systems, as articulated by the Institute of Medicine in the United States. Those approaches to aggressive system engineering need to address the contributors to what has now been called in the literature, “clinical inertia”. This is a manifestation of the fact that we may know what to do about disease either at the personal level or community level, but for one reason or another we just don't seem to get moving. The term “clinical inertia” is increasingly used in a very appropriate description of northern remote communities.

I very humbly think we need to revisit the Hall commission of 1965. Justice Emmett Hall and his commissioners in fact wrote quite clearly about the challenges of northern remote populations, and I would admit that in the last 45 years there has been a change in linguistics but a change in the need to address it, and system resources must be brought into play such that we can address the evolving patterns of illness.

Last but not least, I would say that patients and the communities always need to be engaged and empowered so that we can move along to address the challenges, the tragedies, and the predictable outcomes in northern remote populations.

Thank you very much.

[The Chair, Conservative, Joy Smith]

Thank you so much, Dr. Martin. I gave you quite a bit of extra time because I knew you were presenting both sides of it.

Dr. Bowmer.

[Dr. Ian Bowmer, Executive Director and Chief Executive Officer, Medical Council of Canada]

Thank you very much, Madam Chair. I really appreciate the opportunity to appear once again before this committee on behalf of the Medical Council of Canada.

As Madam Lefebvre noted, we really do not have a single Canadian licensing system; rather, we have 13 independent jurisdictions. While there is a Canadian standard, each jurisdiction still has the ability to make multiple exceptions.

The Medical Council of Canada was actually founded in 1912 to establish a single acceptable national qualification for these jurisdictions for the practice of medicine in Canada.

At this moment in time we have heard of the Canadian standard and the acceptability of the examination process to each of the 13 jurisdictions. Each graduate from a Canadian medical school must take our examinations prior to entering clinical practice. As Dr. Varastehpour noted, international medical graduates must complete one or more of the Medical Council's examinations to be eligible for licensure.

Each province and territorial regulatory authority determines which examination comprises the minimal requirement for licensure. Every year, over 12,000 candidates, both Canadian graduates and international medical graduates, take Medical Council examinations. These assess medical knowledge, clinical skills, and professional behaviours required of an independently practising physician.

After passing the final examination, the qualifying examination, part II, and meeting all other credentialing requirements, the candidate is awarded the licentiate of the Medical Council. It is one of the requirements that provincial and territorial regulators require before issuing a physician a licence to practise in Canada.

The council has taken the lead on several successful collaborations with the Government of Canada, through Human Resources and Skills Development Canada, Health Canada, as well as partner medical organizations. We've worked together on measures to more easily integrate international medical graduates into practice in Canada.

One such collaboration resulted in the launch of the Physician Credentials Registry of Canada. This is a collaboration between the Medical Council and the Federation of Medical Regulatory Authorities of Canada, and it has received funding through HRSDC. It is a national repository for source-verified credentials. We've been operating this now at the Medical Council since 2007 and are processing approximately 380 diplomas and credential documents per month.

Physicians can submit their documents prior to emigrating to Canada, and international medical graduates applying to one or more jurisdictions can choose to share their verified credentials with multiple organizations at once through the repository, saving both time and effort. While time for verification depends on the source institution abroad and the type of document, the average is approximately 81 days for medical degrees and 108 days for verification of postgraduate education. Of course, there are countries in the world where this is not feasible, Afghanistan being one and Iran another. We do have alternative methods to be able to demonstrate that an individual has graduated from an institution in these countries.

At the moment, the repository is only available to international medical graduates, but our intention is to open it up to Canadian physicians.

The opening of an account with the repository is only the first step for international medical graduates. The second step, as the presentation by Dr. Varastehpour noted, is the Medical Council evaluating exam. The reason for this is that some countries around the world do not have accreditation processes. We in Canada and the U.S. have a joint accreditation process for medical schools that is quite rigorous. Therefore, the need for assessment of physicians' knowledge was considered essential, and in 1979 the Medical Council collaborated with the Government of Canada to offer this examination abroad. Unfortunately, it was only offered through embassies and consulates in about ten places around the world. Since 2008 we have had a computer-based test, now offered in 73 countries at 500 sites, so candidates do not have to travel outside of their country of origin to take this examination.

The examination was always intended for international medical graduates prior to their emigration to Canada. However, at the present time, 50% of those taking our examination do so from inside Canada. Our data show that if a candidate fails this examination one or more times, she or he has a low probability of completing the licensing process, probably less than 35%, as opposed to passing this examination the first time, when the person then has a more than 75% chance of completing the licensing process.

We believe that the federal government should benefit by requiring potential licensure applicants to provide evaluating examination results for consideration at the time of their immigration application.

Dr. Varastehpour is correct that this is an expensive examination. We do it through a delivery system. However, we are also offering a self-assessment examination based on that exam, which individuals can take. We have multiple forms for this. It costs $60 to take this over the Internet, and the individuals get feedback on whether or not they would be successful.

The other aspect of assessment, of course, is the clinical skills. We've been in a collaborative partnership of national medical organizations and the various governments to provide an assessment of clinical skills. These are the communication skills and diagnostic skills.

The final area where we have collaborated has been to establish a national registration process that can be done through the web. This process could start prior to candidates coming into the country as well.

I'll close there. Thank you, Madam Chair.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Bowmer.

We'll now go into our first round of questioning, of seven minutes for the questions and answers.

We'll begin with Dr. Bennett.

[Carolyn Bennett, Liberal, St. Paul's, ON]

Thank you very much.

Thank you all for coming.

I'd like to begin by reading the communiqué from the 2004 health accord, of which one of the items was the strategic health human resources action plans.

There is a need to increase supply of health care professionals in Canada, including doctors, nurses, pharmacists and technologists. These shortages are particularly acute in some parts of the country.

As part of efforts to reduce wait times, First Ministers agree to continue and accelerate their work on Health Human Resources action plans and/or initiatives to ensure an adequate supply and appropriate mix of health care professionals. These plans and initiatives will build on current work in the area of health labour relations, interdisciplinary training, investments in post-secondary education, and credentialing of health professionals. Recognizing the important contribution of health care providers in facilitating reforms, First Ministers commit to involving them in their work in this area. To facilitate better planning and management of HHR, First Ministers acknowledge the need to foster closer collaboration among health, post-secondary education and labour market sectors.

Federal, Provincial and Territorial governments agree to increase the supply of health professionals, based on their assessment of the gaps and to make their action plans public, including targets for the training, recruitment and retention of professionals by December 31, 2005. Federal, Provincial and Territorial governments will make these commitments public and regularly report on progress.

The federal government commits to: accelerate and expand the assessment and integration of internationally trained health care graduates for participating governments; targeted efforts in support of Aboriginal communities and Official Languages Minority Communities to increase the supply of health care professionals for these communities; measures to reduce the financial burden on students in specific health education programs; and participate in health human resource planning with interested jurisdictions.

We need to be reminded of this because this committee has to recommend what the federal responsibility is in moving forward.

My understanding is that a federal-provincial-territorial committee was charged with doing this. I have concerns that the federal participation in that committee has been modest at best. It's better than the national pharmaceutical strategy, where they haven't even appointed a federal co-chair.

If you were writing the recommendations about how the federal government needs to redouble its efforts in taking to heart--obviously in terms of aboriginal health human resources--the areas in which the government needs to show, in terms of the international medical graduate slots, supervised slots, an ability to assess people early, as Ian has said, and if they aren't going to make it, to be able to move them early to physician assistance or hospital lists or be able to use their skills in their own language...

I know what the report card from most people is, in terms of the federal participation in this. Either in this hearing now or for you to forward to us, we would love to know your recommendation on the role the federal government must play in moving forward. Clearly, poaching people from province to province isn't working.

How do we get more health human resources, and what role can the federal government play?

[The Chair, Conservative, Joy Smith]

Who would like to begin with that question? Dr. Bowmer?

[Dr. Ian Bowmer]

I'll jump in, Madam Chair.

First of all, I think assessment is absolutely crucial, and if it can be done in the country of origin and given some sort of direction, that's wonderful. What I think is perhaps lacking in Canada at this moment is the capacity to provide remedial training for individuals who have taken a long time to move through the exams and need some catch-up time, maybe because they have spent two years learning French or English and therefore are no longer eligible for licensure. That can be anywhere from three months to a full residency. The capacity for those individuals is not increasing, and I think that was something Dr. Varastehpour pointed out.

When we hear there are 1,600 or so international medical graduates applying for residency--therefore, by definition, they have been identified as needing remedial activity--and only 350 or 400 are getting in, we have a capacity problem in the country.

[Carolyn Bennett, Liberal, St. Paul's, ON]

Could the federal government pay for those slots and help the provinces out?

[Dr. Ian Bowmer]

Health is a very tricky issue in Canada, Dr. Bennett, as you know. I'm a former dean of medicine, and I would have loved to have had the federal government paying some residency slots when I was in Newfoundland and Labrador. However, I'm not sure my government at the time would have appreciated that intrusion.

There is a need, and perhaps as a program for international medical graduates there is a way in which Immigration Canada or the federal government can have a role, but I am not sure how that can be best applied.

[The Chair, Conservative, Joy Smith]

Ms. Lefebvre.