Human Resources Committee on Nov. 1st, 2011

[Dr. Sandra Murphy]

It's the same. They're looking at transferability from one province to another and using the same standards.

[Michael Brennan]

With regard to physiotherapy, the standard for the highest level of competence entry into practice for physiotherapists across Canada is recognized, and interprovincial is not a problem.

The trick is that limited licence issue again. We've seen a really elegant solution in Quebec that is not even on the radar anywhere else in Canada. I think it ought to be. If we can engage provincial regulators and legislators to start considering immigration policy and the needs to build the labour force through those mechanisms, we might be on to something.

It took 22 years or so to get interprovincial recognition, and maybe we can cut that in half on these limited licence deals. The potential is there; it's getting the conversation going.

[The Chair, Conservative, Ed Komarnicki]

Thank you. You're just about up to your time.

This might be a good place for us to suspend and allow the other panel to come on board.

Thank you very much for your presentations and recommendations. We'll certainly take them into consideration.

[The Chair, Conservative, Ed Komarnicki]

Thank you for your attention.

Just before we get started, as you know, there'll be a vote in the House today. The bells will ring at 5:15, and they're half-hour bells. We're just up the stairwell from the House. I would propose that we go to 5:25 or 5:30, if everyone's agreeable to that. Is anybody opposing that course of action? If not, that's how we'll proceed then by consent.

Having said that, I want to remind the presenters that we'd like you to keep your presentation within the five- to seven-minute range to give everyone an opportunity to ask some questions. We will have three presentations: the Royal College of Physicians and Surgeons of Canada; the Canadian Dental Association; and the Canadian Institute of Health Research.

I believe we'll start with the Royal College of Physicians and Surgeons of Canada.

Go ahead.

[Dr. Andrew Padmos, Chief Executive Officer, Royal College of Physicians and Surgeons of Canada]

Thank you, Mr. Chair.

Members, my name is Andrew Padmos. I'm the CEO of the Royal College and have been that for five years. I'm accompanied by Paul Tomascik, a senior policy analyst with us. I'm a physician by training, a hematologist. I practised mostly outside Canada, in Saudi Arabia, but since I returned in 1993, I've practised in Kingston, Halifax, and I currently continue a clinic in Windsor, Nova Scotia, the home of hockey.

Thank you Mr. Cuzner.

The Royal College feels there is a simple solution that's within reach to shorten the foreign credentials recognition process and to integrate internationally trained physicians into Canadian practice. However, we feel it's important to pause and reflect on the very high standards for which Canada's health system is very well recognized. It's not that we're an organization with a defined self-interest in the profession. The Royal College was created in 1929 to provide the public with assurance that physician specialists--in those days there were only two specialties, physicians and surgeons--were trained to the highest quality so that public confidence could be maintained.

In fact, our organization welcomes the additional physician manpower that would be available through faster immigration processes, and we're taking steps to improve the integration of internationally trained physicians already in Canada. Approximately 1,500 are practising as specialists in Canada but have not yet achieved Royal College certification, which is acknowledged both inside Canada and outside as the gold standard for recognition and registration of specialists' qualifications.

Our standards are sometimes referred to as CanMEDS, Canadian medical education standards for specialists. They've been adopted in 20 countries and jurisdictions around the world because of their value in setting a framework for medical education and training.

We actually have only four recommendations for consideration here, and I don't think this is the first time they've been presented to standing committees of health and human resources here in Ottawa.

First, we recommend that action be taken to reduce and eliminate confusing standards and information present in various websites, both from the point of view of Canadian immigration and from the registration of the medical regulatory authorities in Canada's ten provinces and three territories. Those who are seeking to enter Canada for a variety of reasons deserve a single source of truth in terms of the information about requirements and the process.

Second, a recommendation is that as much as possible there be harmonization of Canada's immigration requirements and process for those individuals who seek advantage in the immigration process by virtue of their medical qualifications. So if they get additional points because they are a physician, we think they should be subject to additional stipulations. There are only really three. First, language proficiency should be established before the immigration process is completed. Second, their primary qualifications of their medical degrees and other specialist certification should be registered with Canada's physician credentials registry, located and supported by the Medical Council of Canada. It provides a one-stop shop for verification of credentials, and it applies to those in Canada, trained in Canada, as well as those outside. Third, all candidates for immigration who anticipate a medical career should do the evaluating examination of the Medical Council of Canada before their immigration process is completed. This is because that's the base qualification required for all medical graduates practising in Canada.

If members of the federal government would like to turbocharge the process, they should consider an additional recommendation, and that is to provide funding for clinical observation periods for those physicians who are trained outside and have qualifications that might warrant them getting a licence to practise. However, we do not support point-of-time evaluation.

We think that in most cases a period of observation of three to six months is necessary, and it is often required by provincial regulators. However, the funding to make this possible for candidates is often sparse and very difficult to process. So additional funding in this area would greatly speed up dealing with a pool of probably 3,000 physicians who are already landed permanent residents of Canada, and sometimes citizens, who have not yet been able to achieve licensure.

Thank you.

[The Chair, Conservative, Ed Komarnicki]

Thank you very much for that.

We'll have a presentation from the Canadian Dental Association.

Mr. Soucy or Mr. Lees, go ahead.

[Dr. Benoit Soucy, Director, Clinical and Scientific Affairs, Canadian Dental Association]

Mr. Chairman, members of the committee, good afternoon. Bonjour. My name is Benoit Soucy. Thank you for inviting me to speak to you today about the licensure process used by Canadian dentistry.

On behalf of the Canadian Dental Association, I will present to you the work done by various components of dentistry to ensure the competency of dentists practising in Canada. Joining me is Robert Lees, the manager of registration at the Royal College of Dental Surgeons of Ontario. I look forward to his assistance and perspective during the question and answer period.

Dentistry is well known for its insistence on the importance of prevention and management of oral diseases. The “bias in favour of prevention” approach is reflected in the way we, as a profession, have approached licensure. To ensure the protection of Canadians seeking dental care, we have put in place a solid four-part process of education, accreditation, certification, and licensure, which guarantees that dentists entering practice in Canada have the training and skills that are needed to deliver safe and effective dental care.

Dental education is delivered at ten universities across Canada in a variety of programs that prepare dentists to meet all the needs of the Canadian population. To support their educational missions, all Canadian dental schools operate dental clinics and research centres, thereby combining in one facility what in medicine is delivered through the faculties of medicine and their academic health science centres.

The Commission on Dental Accreditation of Canada, or CDAC, is responsible for accrediting all Canadian dental and dental hygiene education programs, as well as some of the dental assisting programs. Accreditation is a lengthy, involved, and expensive process that requires regular site visits and considerable expertise. Accreditation provides verification of the quality of the education process.

Certification is the confirmation of the competency of individual applicants for licensure. It is done through the National Dental Examining Board of Canada. The NDEB has a system of examination that is fair and effective and that is recognized as one of the best worldwide.

The last step is licensure, which is the responsibility of the provincial and territorial dental regulatory authorities. All the provincial regulatory authorities for dentistry in Canada accept NDEB certification as the basis for licensure without further testing of qualifications. As a result, all Canadian dentists enjoy full interprovincial labour mobility.

One of the most remarkable features of this four-part process is the absence of any patient-based examination in the certification component. In many parts of the world, this type of examination, despite its many shortcomings, is still seen as essential for the verification of clinical competency. Canadian dentistry has been able to do away with this type of examination by requiring candidates for certification to be graduates of accredited programs and by relying on the confirmed quality of the in-curriculum evaluation.

To facilitate licensure of dentistry outside of Canada, the Commission on Dental Accreditation has been asked to establish mutual recognition agreements with counties that have accreditation systems that can be compared to ours. Graduates of dental programs in countries where MOUs exist are eligible to sit the same certification examination as graduates from accredited programs in Canada. Currently, MOUs have been signed with the United States and Australia, and agreements are being negotiated with New Zealand and Ireland.

While MOUs work well, the number of countries with whom they can be signed is relatively small, and alternative approaches are required to assess the competency of the majority of international applicants. While other occupations use credential assessment services for that purpose, the reality is that for dentistry this avenue is less than promising. Test cases were sent to credential assessment organizations with very disappointing results. Graduates of all test cases were deemed to be equivalent to Canadian grads, despite an enormous variation in the quality of their education. In fact, even graduates from schools with no clinical training at all were given passing marks.

To provide a working alternative, NDEB has been asked by the Canadian Dental Regulatory Authorities Federation to develop, with funding from the federal government, a process to verify the equivalence of dentists trained outside of Canada to graduates from accredited programs. The NDEB equivalency process is brand new and was used for the first time this year. It starts with a voluntary web-based self-assessment designed to allow potential immigrants to gauge their ability to become licensed in Canada before they are committed to moving here. Candidates who choose to seek licensure are assessed on their fundamental knowledge, clinical skills, and clinical judgment in a process that can be completed in less than a year.

Those who successfully complete the three assessments are judged equivalent to graduates from an accredited program and can get licensed in the same fashion. Candidates who fail to complete the equivalency program successfully can apply to a qualifying degree or degree completion program to become eligible to take the certification examination as graduates of an accredited program.

These two-year programs are offered in eight Canadian universities. From 2000 to 2010, they were the only avenue available to dentists from non-accredited programs who wanted to license in Canada. They are our best source of information on the level of preparedness of dentists moving to Canada and showed an immense variation, not only from country to country but in many cases from school to school within the country. Some foreign-trained dentists are essentially at the same level as their Canadian colleagues, while others simply do not even come close to making the grade, even missing some of the prerequisites to enter dental schools in Canada.

The variability is our biggest challenge and the reason a dental degree on its own cannot be taken as confirmation of competency. We either have to have formal knowledge of the educational process through accreditation or we need to test individual candidates in some way.

To wrap up, I would like to thank you again for listening to my remarks. This is a huge policy area and one that has clearly become a priority for this government. I applaud you for consulting with the many groups you will hear from during your hearings, and I encourage you to continue to consult with the Canadian Dental Association on a move forward basis.

We're available to answer any questions you may have.

[The Chair, Conservative, Ed Komarnicki]

Thank you very much for that presentation. We will move to the Canadian Institutes of Health Research.

Ms. Bourgeault, is that you?

[Dr. Ivy Lynn Bourgeault, Advisory Board Member, Health Services and Policy Research Institute, Canadian Institutes of Health Research]

Thank you.

Like the other panellists, I would like to thank you for inviting me to make this presentation to this panel. This is a very important issue.

I want to highlight, however, that I do not represent the Canadian Institutes of Health Research at this table. I am here as a CIHR- and Health Canada-funded research chair in health human resource policy. So I'm here more as an individual.

I have with me my colleague, Anne Brasset-Latulippe, who is the coordinator of the Pan-Canadian Health Human Resources Research Network.

You all have a copy of the presentation I will make today.

I come here as a research chair in health human resources, having worked for the past 10 years on this topic, not only in Canada, but also in the United States, the U.K., and Australia, focusing on the professions of medicine, nursing, and midwifery.

There are two main points I want to make about the recruitment of internationally educated health professionals and their integration into the Canadian health care system.

Just as a backdrop, if we look at this question historically, the role of internationally educated health professionals has for some time been intricately connected with health human resource policy in Canada. We rely heavily on them, particularly during periods of shortages, when we recruit from outside the country and integrate those who have come here through our immigration process. Their integration process becomes much more difficult when there are periods of perceived surpluses or periods of health care cutbacks. Canadians have benefited from this flow, receiving greater access to health care and reduced public costs for health professional training. There are costs, of course, for their integration.

The context I want to put this issue within is a series of ethical codes, the most recent one being the World Health Organization global code of practice on the international recruitment of health personnel. What is interesting, however, in the research that I and my research team have undertaken is that there's very little recognition of these codes. There's a Commonwealth code from 2004. The code in hand was developed in 2010, and there's a requirement to report back to the World Health Assembly on the commitment to this code. Some of the key principles of the code have been recrafted into a Canadian document.

It's beyond the recruitment issue; it's really about the sustainability of health human resources. Some of the key principles include creating a self-sufficient health workforce, however that becomes defined; an aim for transparency, fairness, and mutuality of benefits, not only for the internationally educated health professional, but also for the country where they have had their training and the country they come from; and ensuring that all aspects of the employment of international health personnel are without discrimination of any kind.

There are two aspects of the integration of internationally educated health professionals. The one that you're primarily dealing with is integration into licensed practice, into the profession in this country. This includes national policies and processes surrounding the recognition of their qualifications and licensure at the provincial and territorial levels. So there's the complexity between federal and provincial jurisdictions.

The second issue is the integration into the culture of practice. This matter of cultural competency is often neglected but forms an essential part of the integration process. In all four countries in which I've been doing research, this has been highlighted as a particularly important issue. In research that we've done in Canada, we have seen a variety of barriers that internationally educated health professionals face when they're trying to become integrated into the Canadian workforce. There is English or French language competency, but it's beyond passing the standard language test—they want profession-specific language competency. That's quite important.

There are a variety of different financial difficulties related to the requirements for licensure that are compounded by the time-consuming and sometimes bureaucrat nature of the process. I can speak personally as a Canadian-educated researcher that it has become difficult even for me to understand what the process is to become licensed as a physician, as a nurse, or as a midwife in Canada. I can imagine how difficult it must be for someone coming to this country.

The challenges posed by the lack of opportunity to gain Canadian experience while they're here, trying to become integrated, means they don't gain that much-needed cultural competency. Particularly in the area of health care, which is dealing with issues of privacy, very sensitive issues, this is a very important issue.

The consequence of those barriers includes downward professional mobility, the lack of recognition of qualifications. And the numbers are quite large. The most recent estimate we had in Ontario is that there are approximately 5,000 physicians who are in Ontario and not able to practise. These are quite important numbers to look at.

Canada has developed a variety of different bridging programs. In fact, Canada, among the four countries I've looked at—Canada, the U.S., the U.K., and Australia—has been a leader in those bridging programs. They are quite variable. They vary in length, they vary in purpose, and they vary in effectiveness. Some programs focus on assessment of the existing education and skills to identify needs to train up; some focus on preparation for licensure exams; and some provide some clinical or work experience. Very few provide some familiarity with the social and cultural context of the Canadian health care system.

One particular promising practice that I would like to highlight for the committee is the Access Centre for Internationally Educated Health Professionals here in Ontario, where they take a case management approach, very personalized, and they do career reorientation. It is actually through access to their data set that we know they have a clientele of 5,000 physicians in the province who are trying to make their way into regulated practice.

[The Chair, Conservative, Ed Komarnicki]

Ms. Bourgeault, if you could wrap up, that would be good.

[Dr. Ivy Lynn Bourgeault]

Yes. I will go to my concluding facts.

In highlighting how to make the integration process easier, we have to also note that it may have the unintended consequence of drawing more people here from other countries, which contravenes one of the principles here.

Another challenge is that of reducing discrimination against internationally educated health professionals while diminishing the negative effects of their migration on their home countries.

I would also like to stress that a coordinated approach is very much warranted, particularly offered through a pan-Canadian health human resources observatory, which has been recommended by the Standing Committee on Health. I'm just back from Australia where they have an organization called Health Workforce Australia, which provides this coordinated approach. They have a model for us to look at in terms of a coordinated approach to integrating internationally educated health professionals.

Thank you very much.

[The Chair, Conservative, Ed Komarnicki]

Thank you very much.

We'll start with Ms. Crowder.

[Jean Crowder, NDP, Nanaimo—Cowichan, BC]

Thank you.

I want to thank the panellists for your presentations, and particularly the specific recommendations for things the committee might want to undertake. Although this sort of relates to cultural competency, one of the previous panellists raised the issue of racism and discrimination. The Deloitte report actually raises that issue as well. I'll read one brief quote from it:

Some immigrants say that they've been advised to change their name on their resumé or refrain from bringing 'different' or 'smelly' foods for lunch to fit in.

It goes on to talk about one particular employer who had a series of layoffs happening, and 85% of the people on a list of layoffs were highly educated, competent, and ambitious professionals, and all were foreign-born workers.

On the one hand, we're actively pursuing people to come to this country and work, and yet on the other hand it seems there are some real challenges towards integrating people into the workforce, once their credentials are even recognized. Are you aware of any programs that work with employers in Canada around increasing cultural sensitivity, so that when we do have people who are accredited they can then work?

Ms. Bourgeault, I'll start with you.

[Dr. Ivy Lynn Bourgeault]

Yes. I'm not aware of any specific programs, but I do know that through the Access Centre for Internationally Educated Health Professionals here in Ontario, through their case management approach they do provide some support for the employers who hire the particular internationally educated health professionals with whom they are working.

There are also some good models through the Office of the Fairness Commissioner in Ontario to provide some support in that regard.

[Jean Crowder, NDP, Nanaimo—Cowichan, BC]

That's a provincial government program. It's fine once somebody is hired, to work with the employer to help with cultural sensitivity and integration, but how do we even get employers to the place where they're willing to consider foreign-trained professionals?

[Dr. Ivy Lynn Bourgeault]

There are some municipalities--here it's Hire Immigrants Ottawa. It's a particular program from the City of Ottawa that provides incentives and training and support for employers to hire immigrants. It's not specifically focused on health professionals or professionals in general, but that is another program that I'm aware of.

[Jean Crowder, NDP, Nanaimo—Cowichan, BC]

It sounds like a one-off.

[Dr. Ivy Lynn Bourgeault]

Yes, and that is why there's very much a lack of a coordinated approach in this area.

[Jean Crowder, NDP, Nanaimo—Cowichan, BC]

Mr. Soucy or Mr. Lees.

[Dr. Benoit Soucy]

The immense majority of dentists are self-employed and the need to work with employers is not there, but there is a big need to work with the internationally trained dentists to be able to function on their own in the Canadian market,and that is something we haven't been very successful in doing.

We know Canadian dentists have some cultural sensitivity training to know how to deal with patients of different origins and be more efficient at that level, but as far as having national programs to support international dentists, not much is done.

Some local efforts are made. The Royal College of Dental Surgeons of Ontario has an ethics course that is mandatory for any new licensee. It is not necessarily focused on internationally trained dentists. It is for any new dentist who wants to practise in Ontario. That is required, and that might be helpful.

[Robert Lees, Representative, Canadian Dental Association, and Registration Manager, Royal College of Dental Surgeons of Ontario]

The module that Benoit is speaking to recently moved online. It is also free, so although it's a requirement for licensure in Ontario, anyone around the world can take it. The National Dental Examining Board, NDEB, does have a self-assessment tool as part of its armamentarium, but anyone, anywhere in the world, can take our ethics course, which does speak to how dentistry works in this province, ethically, culturally, and legislatively.

[Dr. Andrew Padmos]

Thank you.

The Royal College represents an educational certifying college for approximately half the medical profession in Canada. The other half is represented by the College of Family Physicians of Canada, who are primarily in primary care.

We're in the same situation as our colleagues in dentistry. Most of our members are self-employed, autonomous physicians who have privileges to practise in medical institutions, so they don't have employers, nor is there any organization that sets out a program of orientation or mentoring.

Some of the provincial colleges that are the regulators of medicine have a buddy system as part of their enforced clinical observation period, which provides that orientation, mentorship, and supervision that are very necessary components.

[The Chair, Conservative, Ed Komarnicki]

Thank you. Your time is up.

We'll move to Ms. Leitch. Go ahead.

[Kellie Leitch, Conservative, Simcoe—Grey, ON]

Thank you very much, everyone, for presenting today.

Maybe I could get your comments on a couple of questions.

To go back to what Dr. Padmos was already commenting on, what are your thoughts on how we, as the federal government, can facilitate your specific professions achieving this integration of our provincial colleagues to be able to have the opportunity for the single, national approach for credentialling in your fields? If it be a single source, who should be developing this, and how should they be going about doing that? It would be good to have your input since we seem to be struggling with these professions to be able to achieve that.

[Dr. Andrew Padmos]

The Federation of Medical Regulatory Authorities of Canada, FMRAC, as we know it, has already taken considerable action provoked by the Agreement on Internal Trade. It has established that certification by the Royal College or the College of Family Physicians would be accepted as the gold standard for unrestricted, independent medical licensure. They are rationalizing a vast number of provisional or limited licences to make sure that the qualifications are appropriate and that the progress to full and independent licensure is clear.

They have done quite a bit of work on this objective.