In my previous column, entitled “What are we doing about Canada’s health human resource crisis?” I discussed the serious shortages of health professionals we are facing in Canada, and I highlighted some of the steps that the Royal College is taking to help  address this challenge. Here, I’d like to provide more details on some of the significant progress we are making.  

It is important to note that no organization can solve this problem alone; the solutions will emerge through deep collaboration between systems players who are accountable for those factors affecting both recruitment — including certification and licensure — and retention — including working conditions and well-being.  

We were very pleased to announce an important partnership with Health Canada in December 2023 that will enable the Royal College to make positive impacts in both key areas. Through this partnership, the Royal College received contribution funding in the amount of $4.99 million to advance credentialing processes for international medical graduates (IMGs), and to work with our members and other health care professionals to promote well-being leading to better workforce retention. 

Increasing access for IMGs 

In 2023, the Royal College granted exam eligibility to 485 candidates through our various alternative routes to certification (for candidates who completed their residency outside of Canada). As I outlined in my previous column, there are three routes to certification for IMGs: a Practice Eligibility Route, a Jurisdictional Route and a Practice Ready Assessment Route. These three pathways are growing quickly and with dedicated attention by Royal College staff and the funding from Health Canada, we are targeting further significant growth and an increased rate of processing. Here are some details and recent metrics for each pathway that illustrate the growth we’re seeing.  

Practice Eligibility Route  

The Practice Eligibility Route involves the recognition of competence in practice in another country. The route is for candidates who have trained in a substantially equivalent program outside of Canada, are certified in their home jurisdiction and who complete five years in practice as well as the Royal College exam. The Royal College received 99 applications in 2022 and advanced 69 eligible candidates. By 2023, this had increased to 254 applications with 216 eligible candidates and this year, to date, we have received 443 applications and determined 432 candidates to be eligible.  

The number eligible in the first quarter of 2024 alone represents a six-fold increase in two years and reflects the policy and process changes that have been implemented to expedite access to the pathway. Specifically, the Royal College has removed a Scope of Practice document requirement, which posed a delay for many candidates. Another change permits candidates to access the written examinations as a first step in their PER journey. This allows candidates to complete one of the major PER requirements prior to relocating to Canada, thus reducing risk. Work to improve this pathway continues, including advancing policy changes to consider reducing the requirements for time in practice, or to consider additional credit for fellowship training. 

Jurisdictional Route 

The Jurisdictional Route involves certification by an international college recognized by the Royal College of Physicians and Surgeons of Canada. Certificants from these approved jurisdictions can apply to write Royal College exams and do not require a practice period to become certified once successful. Due to the complexities of this route, the Royal College considered its discontinuation and subsequent replacement with an appropriate alternate route, however; given the current shortage of physicians, we are revisiting the future of this pathway, including exploring reciprocal relationships.  

The Royal College received 219 applications to the Jurisdictional Route in 2022 and advanced 208 eligible candidates. In 2023, this increased to 249 applications with 244 eligible candidates and this year we have received 188 applications and determined 176 candidates to be eligible, to date. 

Establishing the equivalence of training and certification exams recognized by international colleges is a complex process. It is also costly to do so at a time of significant fiscal restraint. That said, the recognition of international certifying colleges that have substantially equivalent training programs and certification exams grows ever more important as our health human resource crisis deepens.  

Practice Ready Assessment Route   

The Practice Ready Assessment (PRA) Route involves the observation and assessment of eligible IMG candidates in Canada by qualified physicians. The Royal College supports this pathway by identifying the competencies required for safe and high-quality care in a given medical specialty, and the means by which those competencies can be assessed. This pathway enables the assessing physician to determine whether candidates are ready to challenge the relevant Royal College certification exam, or if they need to complete additional training. This route is operationalized by some provincial medical regulators as well as funding from provincial ministries of health for the physicians who supervise and assess these individuals, given that the PRA takes place during patient care in real health care settings.  

The Royal College, in partnership with the Medical Council of Canada, has developed two formal national PRA Programs in the high-need disciplines of Psychiatry and Internal Medicine. In addition, medical regulators may nominate other candidates in any discipline that they themselves have put through a provincial PRA. In the last four years, 58 candidates have been nominated through this route. Recently, the Royal College implemented policy that also allows medical schools to nominate candidates, and we are working to expand pilot initiatives (one such pilot exists with Queen’s University in Anesthesiology).  

For the PRA route, the Royal College received 17 applications in 2022 and advanced 17 eligible candidates. This increased to 30 applications with 25 eligible candidates in 2023. We anticipate an increase in 2024 applications following the policy changes to allow nominations from accredited medical schools. 

As critical as these pathways are, our commitment is also to reduce the processing time required by the Royal College to establish eligibility. This processing time has been reduced for most candidates from as much as 18 months to an expected time of 12 weeks. More improvements are expected as the Health Canada funded work continues throughout this year.  

Well-being of current and prospective specialist physicians

It is critical that we, as health care institutions, attend to the retention of those already in practice. We know how important well-being is to retention and there is growing awareness that the shortage of health care providers, including physicians and nurses, is among the factors leading to burnout, in addition to growing clinical demands, funding constraints and the rapid adoption of new technologies.  

Many practice settings, including the hospital in which I work, have appointed physician wellness leads and created offices of well-being. Although well-being (for a healthy person) includes such things as good nutrition, exercise and strategies for relaxation, the work of well-being is much more than that. Ensuring easy access to care for those who develop mental health problems is at the top of the list and should include access to employee assistance programs and clinics provided by departments of Psychiatry and Psychology. Burnout can start very early in residency training and it is never too early to start talking about it with trainees. Rigorous standards of respect and civility are also key to environments that support well-being and ensuring a robust protocol to address professionalism issues when they arise is critical. 

The literature also shows that when physicians feel they have control over their work and are engaged in improving systems and processes, this serves as an antidote to burnout. As a simple example, as part of a multi-pronged strategy, the physician wellness lead in my institution plays a key role in ensuring physicians who are struggling with the electronic patient record get support to advance their skills. This individual also serves on the hospital committee that oversees the evolution of that system to provide a physician lens.  

The Royal College’s partnership with Health Canada includes $3.5 million in funding to collaborate with partners to develop a National Plan for Health Workforce Well-Being to help improve health workforce retention for physicians, nurses and other health care professionals across the career spectrum. 

We are now bringing together six working groups that will be charged with making recommendations in the following key areas:  

• create and sustain positive work environments; 
  
• invest in measurement, assessment strategies and evaluation/research; 
  
• support mental health, reduce stigma; 
  
• engage effective resources; 
  
• institutionalize well-being as a value; and 
  
• recruit and retain a diverse workforce.  

Specifically, for the upcoming year, project activity highlights include  

• Convening the National Collaborative – May/June 2024; 
  
• Assessing Burnout – Nov. 2024 (final report); and 
  
• Convening Working Groups & Inaugural Working Group Chairs Summit – Sept. 2024/Feb. 2025. 
  

We are pleased to be partnering with many national organizations as we advance a collaborative approach that will be solution-based.  

This is just a glimpse of the approaches that will be central to the establishment of the National Plan for Health Workforce Well-Being as the project gets underway. Through this project, our goal is to help members and other health care professionals reach their full potential and find joy in the work they do.  This work, and all other Royal College programs, initiatives and projects, would not be possible without the support of thousands of contributors who serve on our committees, task forces and boards. I truly appreciate the energy and passion they continue to bring to the mission of the Royal College, even now, amid a very stressed health care system. I look forward to sharing more updates as this important work continues.

Brian Hodges is the 47th President of the Royal College of Physicians and Surgeons of Canada. He is the executive vice-president of education and chief medical officer at the University Health Network. A professor in the University of Toronto’s Temerty Faculty of Medicine and at the Dalla Lana School of Public Health, as well as a senior fellow at Massey College, Dr. Hodges is also a practising psychiatrist.