In Canada, we’ve normalized the idea of a struggling health care system. While universal health care is embedded in the Canadian identity, increasingly so too is the notion that the promise of universal health care is broken. Rather than throw up our hands at the complexity of the problem, the Royal College is thinking carefully about the role we can play in remedying this situation.

Specialist physician care is just one component of a robust health system — but it is the component most firmly in our lane, and so our efforts begin with asking what Canadians require of their doctors. We need enough doctors in both family medicine and the seventy-odd specialties and subspecialties that comprise the profession in Canada. We need access to those doctors when and where they are required. And we need those doctors to have the skills to offer care that is current, compassionate, and competent.

None of these imperatives is straightforward. Do we have enough doctors in Canada? In some disciplines, most notably family medicine, the answer appears to be “not even close.” Several specialties and subspecialties also face chronic and seemingly intractable shortages. But, in other specialties and subspecialties, the picture is not so clear, with graduating residents sometimes struggling to find jobs. 

One challenge is the lack of trustworthy numbers or a centralized planning model. To be fair, planning is complicated, as the recipe isn’t a simple doctors-per-1000-population equation. Such numbers often mask problems with physician distribution that compromise equitable access. Changes in everything from the complexity of patients’ health needs to professional norms around working hours to the evolving and still-uncertain role of artificial intelligence mean that any modeling will require numerous assumptions about the future that may or may not come to pass. 

One thing seems clear, however: Canada is not training enough doctors, and hasn’t been for some time. The Royal College therefore endorses efforts to boost medical training in Canada and supports advocacy to ramp up the education of new doctors. But we also acknowledge that increasing Canada’s own medical education capacity is a long game. To address our doctor deficit more immediately, we must also continue to effectively integrate doctors whose medical school and residency training occurred outside Canada. 

Welcoming internationally trained doctors

Of course, Canada already has a large community of internationally trained doctors. These individuals are valued colleagues who share call schedules and patients, exchange advice about tough cases, and contribute to the first-rate care that Canadians expect and deserve. But historically, the Royal College has welcomed into the fold only those specialists who pass our examinations.

This approach is driven by an admirable focus on competence and safety. But the inevitable exclusivity it creates may not be serving the profession or the public well. Some specialists have training that closely resembles Canadian training, but that lacks one or two elements that Canadian standards demand. Some experienced specialists have narrowed their scope of practice over time – as many Canadian trained specialists do. And, for most (perhaps all) specialists, the growing strengths in skill and reasoning that come with experience are accompanied by a decline in the “book smarts” that examinations can demand. 

For all these reasons, the requirement to pass an examination designed for those exiting a Canadian residency may be an unreasonable price of admission for some internationally trained specialists. Medical regulatory authorities seem to agree and are reducing barriers to licensure for physicians trained abroad to improve public access to care. 

As a result, Canada has a few thousand specialists who are licensed to practice but who have not achieved (and may not even be eligible to achieve) Royal College certification. Many of these individuals register with the Royal College’s Maintenance of Certification (MOC) program to track their continuing professional development activities and to meet regulatory and privileging requirements. But they otherwise have no status with the Royal College. We think that needs to change. 

Growing our community

We envision the Royal College as an inclusive community of specialists and a source for career-long support to those who are providing critical medical and surgical care to Canadians. Towards that vision, we are exploring the creation of a new category of affiliation with the Royal College – one that recognizes those who have been certified in other jurisdictions and invites them into our professional community. 

Fellowship in the Royal College will continue to signify that one has met all the Canadian standards for training and demonstrated competence through assessment and examination. Affiliate status with the Royal College would signify substantive existing expertise – even if earned and assessed elsewhere – along with the same ongoing professional commitment to lifelong learning and excellence that Fellowship requires.

Inclusion without support, however, is inadequate. Canadian training standards are tailored to the needs of the Canadian population; training in any other jurisdiction leaves certain things out that we believe are essential to providing competent care in Canada. For example, residents in Canada must develop an understanding of the rights and health care needs of Indigenous peoples and a capacity to deliver respectful and culturally appropriate medical care. 

Furthermore, residents in Canada learn to navigate Canada’s health care systems, develop knowledge of community supports and resources, and embrace critical learning related to issues like planetary health and social determinants of wellbeing. This knowledge and skill is essential, not optional. We aim to leverage our existing MOC system to provide tailored learning to support our internationally trained colleagues as they make the transition to Canadian practice. 

A modernized Royal College

It’s time to modernize the Royal College. Our challenge is to build an inclusive community of specialists while maintaining the standards that have been our trademark for nearly a century. To help us to succeed, we will be consulting with internationally trained physicians, medical regulatory authorities, and our Fellows.  

As always, your feedback is deeply valued and will be essential to the process. We are inviting our members to take part in upcoming focus groups to discuss the possibility of a new affiliate category with the Royal College. We hope you will join us to share your perspective and help shape what comes next. 

Click here to register for a focus group.

If we can get this balance of inclusion and rigour right, both the profession and the public will benefit.

Sincerely,
Chris

Chris Watling, MD, FRCPC, MMEd, PhD
Chief Executive Officer