Health Committee on April 1st, 2010

[Dr. Ali Varastehpour]

I would like to make a couple of comments on one point that I forgot to bring up in my presentation.

I heard that in Manitoba there is a very good program. They have their own exam. I'm not sure if my information is up to the mark, but Dr. Martin may be able to supplement it. You take their exams, you pass their exams, you work one year in a rural area--wherever they send you--and then you are a licensed physician. I know persons who are doing orthopedic surgery after that process. People say that Manitoba and Alberta have the best prospects, Manitoba because of that so-called streamlined approach and Alberta because Alberta has more money.

That is one point to remember, because if one province comes up with a better idea, that idea should be promoted. Instead what the regulatory bodies are doing, or whoever is in charge, is creating bogus--I am sorry to use that word--barriers. One of them is the clinical assessment test. As a physician I am willing to volunteer here and ask one of the physicians in the panel to perform a physical examination of the chest on me. I bet that if you brought a second physician from the university, they can fail each other. There are physical examination textbooks that are five pages and others that are 500 pages.

My question is this: if I am a physician and I have a licence and I take a responsibility for treating you as a patient, I can choose to listen to your heart for ten minutes or I can put it on your clothes. This is against the classic teachings of medicine, but how many physicians actually do that? There are lots.

Another example is that they are teaching us to start interviews in a really artificial way, by asking, “Tell me what you feel”, or “Do you have any idea of this disease?” How many times has each of you gone to the doctor and seen that kind of approach? We are forced to do it. Last year almost everyone from Edmonton, except one person, failed this exam.

If you come with something that is important to you, at least provide one month of training on something like ACLS or CPR. Teach it and then examine it. Any physician will tell you that in the United States, basically... There are published articles on sensitivity and specificity of physical examinations. It is next to zero. This is not something I say, and I never promoted it when I was supervising medical students, but that is a different issue.

I just wanted to raise the issue of Manitoba because I forgot to bring it up.

Would you please repeat the last question that you had?

[Colin Carrie, Conservative, Oshawa, ON]

I think I'm out of time.

[The Chair, Conservative, Joy Smith]

I'm sorry, Dr. Carrie. We're now going to Ms. Wasylycia-Leis.

[Judy Wasylycia-Leis, NDP, Winnipeg North, MB]

Thank you very much.

I want to go back to Dr. Bowmer's comments, and Carolyn Bennett also raised this issue about the Canadian health human resource strategy back in 2004. It was part of the accord, and that accord is coming to an end.

It seems to me that very little has been done on that strategy. I'd like to know what has been done, if anything. What can we do to get something done before the end of the accord? I'll pose a rhetorical question: isn't that the basis upon which we should address all of these other issues? If we haven't dealt with that national framework approach when it comes to health human resources, how do we proceed on dealing with the question of foreign credentials, lack of doctors in northern and remote communities, inclusion of the aboriginal community, and so on?

You can go first, and then we'll hear from anyone else on this issue.

[Dr. Ian Bowmer]

Madam Chair, I am here as the CEO of the Medical Council of Canada. I also happen to be the vice-chair of the Health Council of Canada, so I get mixed up sometimes with the data that I am delivering. I can't answer that question from the Medical Council's perspective; I can only answer from a personal perspective.

It seems to me that the health human resource planning aspect has dropped off the agenda, or at least dropped off the national or the pan-Canadian government agenda.

There has been some really successful re-engineering, as was mentioned, without increasing the physician resource. Alberta has good examples. There have been good examples across the country, but they're very patchy, and I think what has been lost in this is the idea that we were supposed to start with a needs-based assessment of the population. We were supposed to have provincial targets, and it was supposed to be driven at a pan-Canadian level. It seems to me that somewhere in the last five years, that has disappeared.

[Judy Wasylycia-Leis, NDP, Winnipeg North, MB]

Is there a body in place that is supposed to be doing this work? Is there a federal-provincial committee of deputy ministers? What exists, and what should be kick-started?

[Dr. Ian Bowmer]

As I understand it , the oversight committee for this is ACHDHR, the advisory committee on health delivery and human resources, and it is a federal-provincial committee. It's the only one of the three committees that were established after the accord that is still surviving, and it is the one that's responsible for health human resource discussions. There are co-chairs there, and perhaps the committee would like to talk to them.

[Judy Wasylycia-Leis, NDP, Winnipeg North, MB]

That's not a bad idea, in fact. I think we should consider it. Yes, we should do that.

Does anyone want to add anything?

Dr. Martin, have you been involved in any interprovincial or federal-provincial discussions around a pan-Canadian approach to health human resources in Canada?

[Dr. Bruce Martin]

I have to say that I have been involved, but those discussions, to use Dr. Bowmer's term, are somewhat patchy. They are programmatic in the regions in which I work; it's not part of a comprehensive system re-engineering. I have active discussions with my colleagues and partners--clinicians or government individuals in our province and in our neighbouring province and territories--but it's not as part of a concerted pan-Canadian approach. That doesn't mean that some of those don't exist; I'm just not a party to them.

[Judy Wasylycia-Leis, NDP, Winnipeg North, MB]

Dr. Fleur-Ange Lefebvre, I imagine it would be useful, from the point of view of your federation, to connect with a body that is actively pursuing the broader question of health human resources from a federal-provincial point of view, or am I putting you in an awkward spot?

[Dr. Fleur-Ange Lefebvre]

Not at all. Before I went to the federation, I worked for the Canadian Medical Association for ten years, and we've been waiting for this for a very long time.

Anything that helps guide the process, that guides the system, and that helps you manage resources that you need to put into the system to make it work is useful.

Are the medical regulatory authorities themselves HHR planners? They are planners only when directed to do so by the minister of health in each jurisdiction. Their job is to ensure that the physicians who are there are qualified to practise medicine.

[The Chair, Conservative, Joy Smith]

Thank you so much.

Now we'll go to Ms. Davidson.

[Patricia Davidson, Conservative, Sarnia—Lambton, ON]

Thank you, Madam Chair, and thanks very much to our presenters this morning.

My first question is going to be to Ms. Lefebvre.

In your opening remarks you referred to the chart that outlines the licensed physicians in Canada. Is that the chart you were referring to, the one that compares the numbers of CMGs and IMGs?

[Dr. Fleur-Ange Lefebvre]

Yes.

[Patricia Davidson, Conservative, Sarnia—Lambton, ON]

You made the comment that in some instances the IMGs showed greater increases than the CMGs. Could you elaborate on this chart and on that comment, please?

[Dr. Fleur-Ange Lefebvre]

I was going to give you the actual calculations, and then we realized that the way people were reporting provisional licences was a bit different from jurisdiction to jurisdiction. However, I did bring something with me from the registrar in Newfoundland and Labrador, Dr. Robert Young.

I can tell you the total number of IMGs who received new licences, both full and provisional, in 2009. I should tell you that in getting full licences, they may have moved from provisional to full, but there were 90 new licensures. Remember, Newfoundland is a smaller jurisdiction, and the total number of licences awarded to graduates of Canadian schools was 49, so there are jurisdictions...

Ontario is the other one. If you do the actual math, as I said, for the provisional licenses in Ontario, the data are pretty solid, but Ontario had a big splash last year. For two years in a row they licensed more international medical graduates--new licences--than they did graduates of Canadian schools.

This move to see this group of physicians as extremely valuable in the Canadian system is very much alive and well. What we want to do is make sure of, within the context of the agreement on internal trade, is that once they're licensed, they're also eligible for mobility. There is a lot of work to be done, but stay tuned.

[Patricia Davidson, Conservative, Sarnia—Lambton, ON]

Thank you.

Dr. Varastehpour, in your comments this morning I certainly hear a huge amount of frustration with the system and with the access to the system by the IMGs. Do things change once IMGs are here, or is it a lack of understanding before the immigration process? Where does the discrepancy arise, or what are the expectations before the immigration process?

[Dr. Ali Varastehpour]

I believe every IMG expects to take some exams. I have never heard any colleague ask why they examine us. I think I'm more qualified to examine the Medical Council of Canada, but that's my personal opinion. I'm an immigrant, and I should abide by the rules. I don't think it is fair. I don't think it is square.

As I mentioned, it favours Canadian students because they collect the questions, and again this is another well-known fact that all of the medical students here know. But the issue is if there were a rule of law, at least we would have had an equal place to compete.

Some provinces allow you to participate in the match, some don't; some places first iteration, some places second iteration. In Alberta it's really strange, they just tell you you have to wait until their own homegrown system does something.

[Patricia Davidson, Conservative, Sarnia—Lambton, ON]

But do you know before the immigration process begins?

[Dr. Ali Varastehpour]

I knew, and I was USMLE-certified. The textbook that people read here says for Canadian qualifying exam and USMLE. That means they're comparing their own exam with USMLE, which is not really a fair comparison. That is a far more difficult exam.

Still, even if it is the same exam, why didn't they put me right into the next step? So passing and not passing the exam is completely irrelevant when it comes to the EE, the evaluating exam. There are people who pass the EE and get a job right away. That is what I'm emphasizing here again and again. I have passed the EE and I can show you one and I have a TOEFL exam and I'm sitting. I don't know, I hope I can make $100 one night if they call me--if.

This is not acceptable. I don't say you hand everything to me on a golden platter, but you see it is being handed over to foreign nationals, and this has not happened in any other country.

[The Chair, Conservative, Joy Smith]

Madame Lefebvre, I think you wanted to make a comment.

[Dr. Fleur-Ange Lefebvre]

It's just a general comment to the committee to suggest that you may also benefit from hearing from the College of Family Physicians of Canada. I believe you have heard from them before.

On their programs for context-specific eligibility routes to their certifying exams--and success at their certifying exams leads eventually to a full licence--they are doing some really interesting work.

[The Chair, Conservative, Joy Smith]

Okay.

Now we'll go to the last questioner, who will be Dr. Duncan.

[Kirsty Duncan, Liberal, Etobicoke North, ON]

Thank you so much, Madam Chair.

I'm going to ask, with respect, if the answers can be kept short so I can get through this.

I think what we've established is that the medical exams are expensive, that there's a significant gap between the pass rate for IMGs and Canadian grads of about 30%. What assessments have been undertaken to explain the poor pass rate, and has cultural bias been explored?

[The Chair, Conservative, Joy Smith]

Dr. Bowmer.