Health Committee on Nov. 20th, 2025

[Dr. Keri McAdoo, Chief Executive Officer, Physician Assessment Centre of Excellence]

Good afternoon, Madam Chair and honourable members of the committee.

I am Dr. Keri McAdoo. I am the CEO of Nova Scotia's Physician Assessment Centre of Excellence, which I'll refer to as PACE. I practised as a family physician in rural Nova Scotia for 20 years and then served as the deputy registrar at the College of Physicians and Surgeons of Nova Scotia. In the last seven years, I focused on developing licensing pathways for internationally trained physicians. My background led me to this role.

I appreciate the opportunity to appear before you today. I will be talking about PACE as a scalable, innovative solution, which is improving access to care by way of assessing internationally trained physicians, who represent 20% to 25% of the Canadian medical workforce and have long been a cornerstone of Canada's health care system, particularly in remote and rural communities.

PACE was established on two central principles. First, there's a substantial global cohort of highly competent, internationally trained physicians who wish to practice medicine in Canada. Second, as a rigorous workplace-based assessment, PACE can evaluate physician competence without lowering the bar.

PACE is the first program of its kind in Canada. Its launch in 2025 was made possible through partnership with the Medical Council of Canada and the College of Physicians and Surgeons of Nova Scotia through the leadership and support of the Government of Nova Scotia. The college took the lead on developing PACE, which is now an independent federal non-profit.

PACE operates through three integrated components. First, it is a comprehensive, workplace-based, competence-focused assessment program delivered by well-trained physician assessors. Second, it is a primary care medical clinic providing access to care to thousands of patients who would otherwise be without a provider. Finally, it is a four-day orientation program designed to support physicians new to Nova Scotia as they integrate into our health care system and into our communities.

Allow me to briefly outline how this model functions. PACE provides a pathway to independent licensure for internationally trained physicians who may already be in Canada or may be arriving as new immigrants. Assessments are conducted by fully licensed physicians, trained extensively by the Medical Council of Canada. These assessors are well-compensated for their expertise and are deeply committed to contributing to this innovative solution.

It's important to note that this is not adding to the workload of these physicians but reconfiguring it. Many of their patients, for example, are now patients in the PACE clinic. The internationally trained physicians deliver direct patient care, while being closely supervised by on-site assessors.

PACE also operates as a health home for thousands of Nova Scotians who previously lacked access to primary care providers. Upon successfully completing the assessment and obtaining independent licensure, physicians transition out of PACE and into practice and take on their own patients.

Supporting physicians to integrate into practice plays a key role in retaining these physicians. The College of Physicians and Surgeons offers a four-day orientation program, the welcome collaborative, designed to help internationally trained physicians transition successfully into medical practice in the province. The welcome collaborative also connects physicians to other supports to assist with settling into a community. Since its inception three years ago, 223 physicians have completed the program, and feedback has been overwhelmingly positive.

PACE is expanding. A second clinic will open in December, doubling our capacity. Once both sites are fully operational, we anticipate beginning up to 45 assessments per year. By the end of 2026, we expect to have assessed 64 physicians in total for licensure. Given the size of our province, this represents a transformative increase in physician supply. We estimate the PACE clinic will provide primary care to 6,500 patients by the end of next year.

PACE is expanding beyond primary care. We have created a hospitalist assessment program to address the significant shortage in our province. We anticipate running 30 assessments in this program in 2026.

None of this would be possible without the leadership and financial support of the Government of Nova Scotia and the College of Physicians and Surgeons of Nova Scotia, or the collaboration of the Medical Council of Canada and the Nova Scotia Health Authority.

This year, PACE was honoured to receive the innovation in physician assessment and remediation award from the Coalition for Physician Enhancement, recognizing our program as a global leader in physician assessment innovation.

Thank you for the opportunity to speak with you. I'm happy to answer any questions.

[The Chair, Liberal, Hedy Fry]

Thank you very much.

I'll now go to Dr. Nickerson, Association of Faculties of Medicine of Canada.

You have five minutes, Dr. Nickerson.

[Dr. Peter Nickerson, Past Board Chair and Dean, Max Rady College of Medicine, University of Manitoba, Association of Faculties of Medicine of Canada]

Thank you very much.

My name is Dr. Peter Nickerson. I am past chair of the Association of Faculties of Medicine of Canada, dean of the Max Rady College of Medicine and a professor of internal medicine at the University of Manitoba.

As an overview, I want to highlight that at the completion of an undergraduate medical doctor degree, graduates are matched to residency positions in Canada via the CaRMS match. People in residency positions are considered paid employees of the health care system in the province where they are working, and residents are also registered learners in an accredited training program in an approved medical school affiliated with the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada.

International medical graduates are individuals who have graduated from a medical school outside of Canada. They are allowed to apply for residency in Canada if they meet criteria. They are matched to a residency program, again via the CaRMS matching process.

One in three international medical grads applying to CaRMS is a Canadian or a permanent resident who has undertaken medical school abroad due to a lack of space in medical schools in their home region in Canada. The ability to accommodate international medical graduates in a CaRMS residency match is dependent upon sufficient provincially funded residency training capacity for both Canadian medical school graduates and international medical graduates.

Visa trainees are foreign-born trainees whose home country is often paying for them to undergo clinical training in a Canadian residency program. These individuals are accepted by Canadian medical schools and health systems only after Canadian medical grads and international medical grads fill all provincially funded residency positions and there remains residual capacity for training in the health system. In 2023-24, there were 3,140 visa trainees working and learning in Canada.

Internationally trained physicians are physicians who are fully certified to practise medicine in their discipline outside of Canada. To enter practice in Canada, they must meet provincial regulatory standards. This may be a simple review of their training and practice record or a formal assessment of their skills before obtaining a licence to practise.

To give context to this discussion, I have prepared three slides for your review.

On the first slide, you will see Manitoba's medical school training capacity, which in 1982 was 95 seats per million population. Government decreased funding in the 1980s, such that by 1994, the incoming class size was 60 seats per million population. By 1998, in recognition of the physician gap that was created, the seat capacity was progressively increased, reaching 90 seats per million by 2009.

However, in 1999, while the medical school class was expanding, the province stood up a formal internationally trained physician program, especially in family medicine, either as a practice-ready assessment, or PRA, or as a one-year training program to get them ready to practise in Canada.

Unfortunately, as the Manitoban population grew after 2009, there was no expansion in medical school training capacity to keep our seat number at 95 seats per million population. In essence, since 1980, Manitoba, by not maintaining its training capacity steady at 95 seats per million, missed the opportunity to train over 800 physicians. When you look at the gap in Manitoba physicians per million population relative to the Canadian average, you start to understand why we have a shortage in Manitoba.

This is not unique to Manitoba. The same pattern occurred in Canada as a whole.

As one potential solution to the health workforce problem, we can increase the training capacity of medical schools in Canada. Slide two shows the capacity by province. While we have increased our seats across Canada, there's a marked regional heterogeneity. Of note, only one in five applicants to medical school is admitted. Many of those not admitted are quite capable of undertaking the training, but there isn't funded seat capacity to train them. Hence, many Canadians go outside Canada to train.

We could also increase the funded residency positions in Canada. The fact that we're able to accommodate externally funded visa trainees tells us that there's further training capacity in the health system, but the provinces are not funding this capacity.

In slide three, you see the national ratio of residency training spots relative to Canadian medical graduates. In 2018, the ratio is essentially 1:1, and it has increased gradually back to 1.12 in 2025, meaning there are only 12% more funded residency positions than there are Canadian medical graduates. This 12% affords the capacity to accommodate international medical graduates in Canada while meeting the needs of our own medical graduates. In Manitoba, we've actually created our capacity at 1.3 as a ratio, going up to 1.72 as of late.

The third solution is to increase capacity to assess or train internationally trained physicians. Provinces can improve recruitment and retention of internationally trained physicians by enhancing practice-ready assessment capacity or, as in Manitoba, by developing a one-year training program in family medicine for ITPs who require exposure and experience to accommodate to the Canadian health care system.

Thank you very much.

[The Chair, Liberal, Hedy Fry]

Thank you very much.

I now go to the question and answer segment. This first segment is six-minute questions. The six minutes include questions and answers, so I'm asking everyone to be succinct. Then we will move on to a second round if we have time.

I'll start the six-minute round with Mr. Strauss from the Conservatives.

[Matt Strauss, Conservative, Kitchener South—Hespeler, ON]

Thank you, Chair.

Dr. Nickerson, thank you so much for your remarks. I just want to quote from the briefing materials you sent us because I think it's so important, and I feel like the committee has missed this point several times.

You said, “The fact that we're able to accommodate externally funded visa trainees tells us that there's further training capacity in the health system”. Do you have reflections on that? It seems to me that every spot that goes to a visa trainee could be going to a Canadian if they were properly funded. Is that a good paraphrase of what you said there?

[Dr. Peter Nickerson]

I think the answer is that the health system pays for residency positions. It pays the salary of these individuals, and it pays the associated training costs to the universities to oversee them in their programs. It's really up to the provinces to decide how much they're going to fund, how many residency positions they're going to create.

[Matt Strauss, Conservative, Kitchener South—Hespeler, ON]

Thanks.

I also have a follow-up question about Saudi trainees in particular.

Could you give us an idea of how much funding medical schools get per Saudi visa trainee and how that compares to comparable provincial funding across Canada?

[Dr. Peter Nickerson]

The cost per trainee, I believe—and I'd have to get back to you with the exact number—is around $70,000 per year. The cost for training a Canadian individual is at the same level. We basically are charging what it would cost us to train an individual, a Canadian individual.

[Matt Strauss, Conservative, Kitchener South—Hespeler, ON]

I just want to make sure that's on the the record, then, because there have been different things that have been said.

Your understanding is that the Kingdom of Saudi Arabia gives the same amount of money per visa trainee that a province would give to a Canadian trainee?

[Dr. Peter Nickerson]

Would give to a...? I'm talking now about the funding that comes to the medical schools to support the training program. That's correct.

[Matt Strauss, Conservative, Kitchener South—Hespeler, ON]

Could you table data on that? I would love to see it in black and white.

[Dr. Peter Nickerson]

Yes, we can get that information for you.

[Matt Strauss, Conservative, Kitchener South—Hespeler, ON]

Okay. Thank you.

My understanding is that there are 1,000 Saudi visa trainees in Canada. Seventy thousand dollars times 1,000 is, I believe, $70 million, which, on the scale of the Government of Canada, is not very much money, so I want to tell you a story about why I feel personally scandalized by this.

I'm critical of Chrystia Freeland for many things, but in August 2018, she called for the release of human rights activists in Saudi Arabia who'd been imprisoned for, like, five years because they wanted women to have the right to drive. Then Saudi Arabia pulled funding for these visa trainees and said that it was going to take its trainees back. I was teaching at the Queen's University faculty of medicine at that time, and the administration lost their minds because of the dearth of funding that this would cause.

A few months after that, Jamal Khashoggi was brutally murdered and dismembered. He was a Washington Post journalist who was murdered with a bone saw, and that sort of repression continues in Saudi Arabia to this day. This summer, they just executed a journalist for criticizing the government in tweets.

I personally felt morally scandalized that the faculty of medicine that I was at was lobbying the government to get this money back from a brutally repressive dictatorship. I wonder if you have reflections on that.

Do you think that receiving this amount of money from a brutal, repressive dictatorship morally compromises faculties of medicine in Canada?

[Dr. Peter Nickerson]

I don't know that I'm qualified to answer that question.

What I can tell you is that we provide the same level of training, in general, to these individuals who are visa trainees. I think the ideal would be that we actually fund more of our own capacity to train residents who are going to stay here in Canada. Overall, I think the biggest gap that we have across the country is the number of residency positions through which we have the opportunity to maintain those individuals working in Canada to meet the needs of Canadians.

[Matt Strauss, Conservative, Kitchener South—Hespeler, ON]

Okay. I'm going to push you a bit on that because I think we all have to be kind of qualified to make our own moral decisions in life.

The faculty of medicine that I was at was lobbying the government and basically criticizing Chrystia Freeland's criticism of Saudi Arabia's human rights record in order to get that money flowing back into their medical school.

Do you recall that episode? What thoughts do you have about that episode? Which faculty of medicine were you associated with at that time? Was that faculty of medicine also criticizing Chrystia Freeland for criticizing the brutally repressive regime in Saudi Arabia?

[Dr. Peter Nickerson]

Thank you.

I would have been at the University of Manitoba. I would not have been in my role at the time as dean. The University of Manitoba does not look at visa trainees as a mechanism of funding that we're dependent upon. We look at the provincial funding that we get at the medical school as being our core funding. If we're funding for visa trainees, that's capacity that we've allowed within the system, but it's not something that we're lobbying anybody for.

[Matt Strauss, Conservative, Kitchener South—Hespeler, ON]

Thank you.

We have heard testimony from the group that represents Canadians who graduated from medical school abroad and want to come back. There are about 800 trainees per year who can't find a spot through CaRMS. The representative of that organization said that they've offered to provide funding. Municipalities as well as foundations, charities and ethnic associations have offered to fund their trainees to come back home.

Why won't faculties of medicine accept that funding, while they do accept funding from Saudi Arabia?

[Dr. Peter Nickerson]

Again, I can't comment on individual municipalities because we haven't received that.

What our government has done in Manitoba has given us sufficient funding to have a ratio of 1.72 currently, so we can actually repatriate Canadians back into Manitoba along with other IMGs.

[The Chair, Liberal, Hedy Fry]

Thank you. That's the end of that session, Mr. Strauss.

I will now go to Mr. Powlowski from the Liberals for six minutes.

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

Dr. McAdoo, do you get federal funding from the province?

[Dr. Keri McAdoo]

That's correct.

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

The money comes in because...?

I still practice a bit of medicine. I get fee for service, and when we bill to the provincial health care system, I get paid. Does that 100% fund your PACE centre?

[Dr. Keri McAdoo]

The provincial government funds it—

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

Does it directly rather than...?

Do you get an annual amount rather than getting paid per patient seen or per services provided?

[Dr. Keri McAdoo]

That's correct. It's an annual amount because it is both providing health care as well as providing assessments. It's not a typical clinic in that regard.