Health Committee on April 1st, 2010

[Dr. Fleur-Ange Lefebvre]

Thank you.

I think there are two things, and both of them are pretty similar to what Dr. Bowmer has already said. On the capacity issue, assessment in the country from which the IMG is applying to enter Canada is important, but it's also important to realize that there will be a clinical observation period, and those are extremely resource intensive. If we're trying to standardize how this is done across the country, there may be an opportunity to pool resources. There is only so much you can do in a centralized or regionalized system because at one point it has to be practice-relevant. It has to happen in the setting for which the licence will be awarded, but there are several issues that could be pulled together in a form of either a centralized or regionalized assessment modality for the period of clinical observation. You cannot bypass that before you award any kind of licence.

The second issue comes back to the expectations. We hear these stories all the time, particularly at the IMG symposium: “That isn't what I was told before I came to Canada”. That is frightening.

We think the Foreign Credentials Referral Office is doing a wonderful job, because they are revving up the information that is being shared. However, what I keep telling them is they are now dealing with a group of people who have already been approved to come to Canada. We need to talk to these people before they make the decision to come to Canada.

That's what I'd like to say.

[The Chair, Conservative, Joy Smith]

Thank you so much.

Monsieur Dufour.

[Nicolas Dufour, Bloc, Repentigny, QC]

Thank you very much, Madam Chair.

I also want to thank all the witnesses for being here today.

Of course, you will understand that, when it comes to the federal government's involvement, we take a totally different view than the Liberals. Mr. Bowmer had it right earlier when he said that, first, each province must decide on its own evaluation. When you say you are not so sure that your government would have appreciated certain intrusions, I totally agree. I am not sure whether my government would appreciate some of those intrusions either.

That being said, I just have a question for Bruce Martin. In terms of the approaches taken by California and Manitoba regarding their faculties of medicine in rural areas, we had an extremely interesting debate at the beginning of the week. Could you explain in a bit more detail the approaches that California and Manitoba have taken?

[The Chair, Conservative, Joy Smith]

Who would like to do that?

Dr. Martin.

[Dr. Bruce Martin]

Thank you very much.

I could describe the program at the University of California, in Los Angeles. When the State of California recognized the need to increase the number of medical students and therefore practising physicians, it made a determination that making more of the same would perhaps not address the needs in under-served populations. So UCLA developed a program called UCLA PRIME. It selectively recruited individuals who would do two concurrent degrees: an MD degree to contribute towards the practice of medicine, and a master of public health. It's an extended five-year program instead of four years, but it gives the individuals a distinctly additional skill set to address the needs of distinctly different populations.

I believe they are now close to their first iteration. It is selective recruitment, unique curriculum, and additional skill sets so when they graduate with the MD degree and post-graduate training they have additional skill sets to move into communities of higher need.

The program in Manitoba is a unique and innovative approach. It has not yet been announced by the federal government. The announcement by the minister was to have been last week, and it has been moved to the end of April.

The federal government is partnering with the University of Manitoba, the College of Family Physicians of Canada, and the Government of Manitoba to increase the number of residency positions and the intensity of the training of a select pool of family practice residents to address the needs of northern and remote communities. They are generally those of aboriginal ancestry in northern Manitoba, Nunavut, and a portion of the Northwest Territories.

This is unique. It is the first time, to my knowledge, that the federal government has embarked on a contribution to residency education. There are ten provincial spots that are funded. And for this intake, there are an additional five funded federal spots. Next year there will be ten federal spots funded, for a total complement of twenty post-graduate trainees. Part of their training will be in southern Canada, with a traditional program in family medicine. An extensive component will be trained in remote communities, precepted by experienced physicians in remote and specifically aboriginal health care. These are not just family physicians, but specialists, medical specialists, and other health care professionals who are embedded within communities.

I trust that answers your question.

[Nicolas Dufour, Bloc, Repentigny, QC]

Thank you very much. I have no other questions.

[The Chair, Conservative, Joy Smith]

Thank you, Monsieur Dufour.

We'll now go to Ms. Wasylycia-Leis.

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

Thank you, Madam Chairperson.

Thanks to all of you.

Let me start with the Manitoba connection first. I think the northern medical unit is a model that could be used in our report to the House of Commons for action planning in the future.

Dr. Martin, you touched on the success that Manitoba has had in terms of recruiting medical graduates, and the retention rate for post-graduate studies is growing as we speak. There was a recent news report by Jen Skerritt on the success we've had in that regard. I'm pleased to hear that the federal government is involved at that level.

You addressed a broader issue as well, and that is the question of clinical inertia. That's something we've heard over and over at this committee, especially as we've dealt with H1N1. We'll hear it again when we discuss tuberculosis in a couple of weeks.

I know that with the limited budget and scope of the northern medical unit you've been able to overcome that clinical inertia and attempt to do some systemic engineering of the system. What lessons would you give us? What have you learned? What can be applied to the rest of the country? What role could the federal government play in terms of resourcing and leadership to take it to the next step? I know it's a broad question.

[Dr. Bruce Martin]

It is a broad question. Perhaps, if you don't mind, I'll start with an opening statement.

I very much appreciate your commendation of the university's northern medical unit's work, but I would also caution you by saying that in my decades of involvement in university-affiliated programs, we still are falling remarkably short. We're falling short in recruitment and retention, and our percentage of complement of practitioners is profoundly low. We fall short in our ability to address some disease entities, although recent published peer-reviewed literature has identified that where we work and where similar organizations work, the outcomes are better, but the outcomes are far from what the Canadian mainstream population faces.

With that apologia, I would say that yes, we have made some movement in the decades we've been involved in care, as have other Canadian university medical school affiliated programs, but we need to take a look at that model, intensify it.

Where can the federal government help? I think we need your assistance and that of the provincial and territorial leaders to clearly define the health human resources need in terms of skill set. I think we need to identify what the competencies really are for health human resources or health professionals' communities, whether they be physicians, dentists, rehab therapists, nurses, or unregulated health professionals. We need to establish educational programs to assist individuals in getting that skill set and maintaining their competency.

I think unfortunately there's often an underestimation of the skill set, and the mainstream education system does not address the evolving patterns of epidemiology in the communities, so that physicians, nurses, and others are profoundly challenged to address the needs. This becomes an issue for recruitment but also for retention, as they feel increasingly comfortable in the needs they must have.

So increasingly a partnership between the federal-provincial-territorial leadership, the academic institutions, and the regulatory bodies that assist us in attaining and maintaining competency in a very unique and challenged environment would be the kind of assistance we need.

I think it's generalizing it and revisiting the liaisons between academic health science networks, medical schools, health professional schools, and northern and challenged populations, or subsets of our population, realigning and revisiting that model but also building on the so-called social accountability needs of our medical schools and other health professionals to recognize they need to be educated in and practise with communities regionally, nationally, and internationally to share the expertise that we have and to intensify the expertise to the benefit of the population.

Does that answer your question?

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

Yes, it does. I think it would be useful if you could actually provide any background information about the northern medical unit to this committee for our deliberations. I think that might just help us as we develop our paper and proposals. Thank you.

[Dr. Bruce Martin]

Thank you.

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

Do I have a little bit more time? I know we'll get a second round.

[The Chair, Conservative, Joy Smith]

You have two minutes.

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

Dr. Varastehpour's comments were so forceful and strong that I think I'd like to hear some responses from others about his frustration. Looking at the statistics, it's clear Canada seems to have fallen down on the job over the last several years. According to our researchers, IMGs represented about 23% of the total physician workforce in 2007, and that's a decrease from 33% in the late 1970s. So something's going wrong. I hear what everyone's saying about the system and doing the best you can, but I guess I'd like to know, when there is a level playing field, how do IMGs not get into the system?

[The Chair, Conservative, Joy Smith]

Dr. Bowmer, I think you wanted to make a comment on that.

[Dr. Ian Bowmer]

Yes. Thank you, Madam Chair.

I think it would be inaccurate to say that something's going wrong because the percentage of international medical graduates has decreased to 22%. During that same time, the output of Canadian medical schools has almost doubled. So the relative percentage has decreased, but if you look at the actual numbers, the numbers have been either steady or slightly increasing.

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

But what if you put that in the context of the shortage of family physicians in Canada?

[Dr. Ian Bowmer]

This is another issue. And thank you for opening that one up, because I think one of the major problems we have not discussed in this country is the fact that it may not be the numbers of doctors that is essential, but how the system works, and we're not talking about other health professionals and their roles in the health care of populations.

Work has been done on the fact that, for example, Germany has poorer health outcomes than we do, but they have twice as many doctors per population as we do. Not enough emphasis has been put on re-engineering the system. Canadian medical schools are moving to interprofessional educational models, and we are trying to do some assessment on this.

I think we have to be really careful about the numbers. Dr. Varastehpour pointed out that we have 250,000-plus immigrants a year. At least 500 to 750 of those should be and would be physicians. There should be a commitment, I think, to integrating those physicians into the country. But the fact that the percentage has dropped, one could argue we're moving to sustainability on those percentages as well, and that was another aspect of ethical recruiting of international medical graduates. My own feeling on ethical recruiting is if individuals are recruited, we have an obligation to integrate them into the country's practice.

Madam Chair, a pan-Canadian HHR framework was negotiated a number of years ago, and I was involved in some of the data that went into that, but I haven't heard anyone talk about that.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Bowmer. There was one, that's for sure.

But we'll have to go on now to our next panel member, and that's Mrs. McLeod.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Thank you, Madam Chair.

I'm appreciating the fact that our analyst gave us a process around how international medical graduates come to Canada. There are many steps, and it's quite complicated in terms of organizations. I see all the steps along the way. Probably there are opportunities for improvement in terms of the process.

Mr. Boone, how many spots are available each year in each stream?

[Jim Boone]

I can't speak to that. I don't have the statistics in front of me, so I can't tell what the trends are for the increased number of spots in IMG positions, how many remain vacant afterwards, but I can certainly mine that data and send it to the committee.

[The Chair, Conservative, Joy Smith]

Would anybody else like to make a comment on that? Does anybody also have insight into it?

Do you want to go on to your next question, Ms. McLeod?

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Okay.

Out of the people who apply for a spot, many are turned away. We talk about the costs of training, but how much is also a system capacity issue, in terms of having the capacity to open spots versus the dollars? Is anyone able to speak to that question?

[The Chair, Conservative, Joy Smith]

Who would like to tackle that one?

Dr. Martin.

[Dr. Bruce Martin]

I'm getting a nod for Dr. Bowmer.

I'm speaking now in the context of being an associate dean, undergraduate medical education, and I look at Dr. Bowmer as a previous dean, as he's mentioned, so I'm careful how I answer. This is not specific to my presentation about the northern medical unit and northern health care.

Capacity is a significant issue. As the Canadian medical schools and a new Canadian school have entered into the situation, as the number of undergraduate medical students is being very significantly increased, and there's a concomitant increase in the number of post-graduate training positions, there are huge challenges in the capacity of the health care system to educate those individuals and attain standards of quality education as reviewed by our undergraduate accrediting agencies and our post-graduate accrediting bodies. That might be explored by this committee with other leadership in undergraduate and post-graduate education. And this is not solely in medicine, but as faculties of medicine embrace education of other health professionals, whether they be physician assistants, nurse practitioners, or advanced skills in others, there are issues of capacity.