CIMM Committee Meeting

37th PARLIAMENT, 3rd SESSION

Standing Committee on Citizenship and Immigration

EVIDENCE

CONTENTS

Wednesday, March 31, 2004

º

1645

The Chair (Mr. Sarkis Assadourian (Brampton Centre, Lib.))

Mr. W. Dale Dauphinee (Executive Director, Medical Council of Canada)

º

1650

º

1655

»

1700

The Chair

Mrs. Fleur-Ange Lefebvre (Executive Director, Federation of Medical Regulatory Authorities of Canada)

The Chair

Mrs. Fleur-Ange Lefebvre

Ms. Madeleine Dalphond-Guiral (Laval Centre, BQ)

Mrs. Fleur-Ange Lefebvre

Ms. Madeleine Dalphond-Guiral

Mrs. Fleur-Ange Lefebvre

»

1705

»

1710

The Chair

»

1715

Mr. Art Hanger (Calgary Northeast, CPC)

Mr. W. Dale Dauphinee

Mr. Art Hanger

Mr. W. Dale Dauphinee

»

1720

Mr. Art Hanger

Mr. W. Dale Dauphinee

»

1725

The Chair

Mr. Art Hanger

The Chair

Hon. Andrew Telegdi (Kitchener—Waterloo, Lib.)

Mr. W. Dale Dauphinee

Hon. Andrew Telegdi

Mr. W. Dale Dauphinee

Hon. Andrew Telegdi

Mr. W. Dale Dauphinee

Hon. Andrew Telegdi

Mr. W. Dale Dauphinee

Hon. Andrew Telegdi

Mr. W. Dale Dauphinee

Hon. Andrew Telegdi

Mr. W. Dale Dauphinee

Hon. Andrew Telegdi

»

1730

Mrs. Fleur-Ange Lefebvre

Hon. Andrew Telegdi

Mrs. Fleur-Ange Lefebvre

Mr. W. Dale Dauphinee

Hon. Andrew Telegdi

Mr. W. Dale Dauphinee

»

1735

The Chair

Mr. W. Dale Dauphinee

The Chair

Mrs. Fleur-Ange Lefebvre

The Chair

Mrs. Fleur-Ange Lefebvre

The Chair

Mr. W. Dale Dauphinee

The Chair

Mrs. Fleur-Ange Lefebvre

The Chair

Ms. Madeleine Dalphond-Guiral

»

1740

Mr. W. Dale Dauphinee

Mrs. Fleur-Ange Lefebvre

Ms. Madeleine Dalphond-Guiral

Mrs. Fleur-Ange Lefebvre

»

1745

Ms. Madeleine Dalphond-Guiral

Mme Fleur-Ange Lefebvre

Ms. Madeleine Dalphond-Guiral

Mme Fleur-Ange Lefebvre

Mr. W. Dale Dauphinee

»

1750

The Chair

Hon. Hedy Fry (Vancouver Centre, Lib.)

»

1755

Mrs. Fleur-Ange Lefebvre

Hon. Hedy Fry

Mrs. Fleur-Ange Lefebvre

Hon. Hedy Fry

Mr. W. Dale Dauphinee

¼

1800

Hon. Hedy Fry

The Chair

Hon. Andrew Telegdi

The Chair

Hon. Hedy Fry

The Chair

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CANADA

Standing Committee on Citizenship and Immigration

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NUMBER 006

l

3rd SESSION

l

37th PARLIAMENT

---

EVIDENCE

Wednesday, March 31, 2004

[Recorded by Electronic Apparatus]

º  (1645)  

[English]

    The Chair (Mr. Sarkis Assadourian (Brampton Centre, Lib.)): Thank you very much, and welcome to our hearing, which is pursuant to Standing Order 108(2), a study on the recognition of foreign experience and credentials.

    Welcome to the committee. There is no vote at 5:45, so we can be here up to 6 o'clock. After you make your presentations, we'll ask questions. I'm confident we'll get a few more members of Parliament coming here after the House has dispersed, and we'll go from there.

    Please go ahead.

    Mr. W. Dale Dauphinee (Executive Director, Medical Council of Canada): Thank you.

[Translation]

    Good day. I want to thank the committee for the opportunity to present the views of the Medical Council of Canada on foreign medical credentials.

    With your permission, I'd like present my comments in English. Thank you.

[English]

    There is a handout that we prepared for you in both official languages. What I'd like to do is highlight a few key features and present one graphic to illustrate one of my main points.

    The Medical Council of Canada was actually established by the Parliament of Canada in 1912--as a result of a private member's bill, I might add, since that's where you just were--with a primary purpose of identifying a process by which the qualifications of doctors could be determined and recognized by all provinces. Of necessity, of course, it required the approval of all provinces, something that took 14 years to accomplish and resulted finally in the Medical Council of Canada. Thus, our role is really to provide a qualification process to assess doctors prior to entry into practice, and that includes an examination for assessment of physicians' skills and knowledge. Really, since 1912 we have been actively promoting common procedures and standards that are recognized by all provinces and territories for physicians prior to going into practice.

    With respect to the question at hand, this is a very important one for us as well, and we play a role here. I thought it might be useful for the committee to hear how we go about it. I'm not going to focus on the examination process, because I don't think that's the intent of this hearing.

    The first thing I'd like to say is that we've had a long history where we've collaborated with government officials with respect to international medical graduates coming to Canada. Currently approximately 23% of the practising physician population in Canada graduated from other medical schools--including the distinguished member to my left--and the Medical Council has played a role in facilitating this over these many years. In a sense, the process we use is very similar to what's used south of the border in the United States, and we operate under the same principles and basic regulatory structure as they do.

    With respect to the recognition of credentials, because that's the question at hand, like our confreres in the United States, at the Medical Council of Canada--and Dr. Fleur-Ange Lefebvre will speak about the regulatory community--we approach it in the following manner.

    We accept all medical degrees from all medical schools that are listed in the World Health Organization's list of medical schools and a more recent list from the Foundation for Advancement of International Medical Education and Research, which some of you may recognize if you're familiar with the field, which is a foundation from the Educational Commission for Foreign Medical Graduates in the United States. Those two organizations published lists of medical schools.

    However, we do subject ourselves with these documents nowadays to primary-source verification. The primary reason for that is that it is now possible to construct almost any document that looks like any official document anywhere else, and in fact, just as recently as today we had another example of a document that appeared to be accurate, but in fact, when we checked with the organization where the person had graduated, they could not verify that person had attended and graduated from that school. There was a recent piece in the Globe and Mail that talked about how photographs never lie, but the software can. It is now possible to do almost anything.

    We currently collaborate with the Educational Commission for Foreign Medical Graduates in the United States, which has a similar responsibility in the United States. They have 60 years' experience with a large library of documents, and we can ask them to attest by visual presentation that they think those documents that we have are similar to what they should be, with the appropriate signatures. But because it's possible to construct anything these days, we then do carry out a primary-source verification step. We've been doing that for just the past six or seven months. This can be done in a way that doesn't delay entry into other processes, but once we have the initial response of the ECFMG that the documents appear, with respect to signatures and format, to be appropriate, it does allow a person to undergo whatever subsequent assessments may need to be done.

    I think in our handout there are some details with respect to what happens to individuals after that point in time with respect to our exams. But the context that I want to emphasize here is that as we work at trying to facilitate this process, and work, as I will comment on in a minute, toward a national process rather than having it done by every agency in every jurisdiction in every province, there is an opportunity to look at it as a possible model for other health professions. In that sense, I'd like you to look upon this in the broad context of the many professions you're looking at, and we can tell you about our experiences.

º  (1650)  

    In summary, we do not attempt to assess medical school curricula. Rather, once we document that they have the MD degree, we assess that individual's prior learning and then, subsequently, knowledge and specific skills with respect to the practice of medicine in Canada, such as public health requirements, and so on.

    It must be emphasized that no MD is recognized in North America. When I graduated from Dalhousie in 1964, my MD still required that I go through a similar process. The MD, in itself, does not give you the right to practise in a North American context. You still have to demonstrate what your skills and knowledge are.

    The example I used is that in many parts of the world a medical degree is a general course. I'm not saying in all places, but in many places. In a sense, it's like the analogy of a person with a bachelor of commerce. He has a certain content that he may have gone through to get the degree, but he wouldn't necessarily have the training to function as a certified public accountant or a chartered accountant. It requires an additional process. As you think about the medical degree, that's the context in which we operate, because those programs vary.

    Neither the World Health Organization list of medical schools nor the FAIMER list of medical schools actually have an accreditation process. The names are submitted by various countries to them. For those schools, it's a common belief—but it's not true—that somehow they have been inspected or reviewed, and that in fact candidates and students at those institutions have received training that we take for granted in our accredited schools, both in Canada and the United States.

    The last thing I wanted to comment on in these remarks is the current situation in Canada, above and beyond what I've told you that we do. I'll be pleased to answer questions on the former part, as well as on this part.

    There has recently been a national task force on the licensing of international medical graduates, which I had the honour of co-chairing with a colleague from Calgary, Dr. Rodney Crutcher.After a meeting we had in Calgary in 2002, almost every body or organization involved in the recognition of foreign credentials for physicians felt that things weren't working as well as they should. There were many groups involved. There were lots of people who had the potential to be enablers to facilitate it, but somehow it wasn't working.

    A conference was brought together in Calgary, where there was unanimity that we could do a better job and that better coordination was required. Hence, a task force was appointed by the Conference of Deputy Ministers of Health. If you happen to have my presentation in front of you, on page 4, under the heading “Current Challenges in Canada”, the conference identified four major issues.

    First of all, there are plenty of enabling mechanisms to assist international medical graduates in Canada, but they need to be better coordinated.

    Secondly, Canada has the expertise needed to undertake, alone or in association with others, such as the ECFMG, all the needed special services to improve access to assessment and better credential services in Canada. We have the enablers.

    The current attempts to coordinate these services and steps within a federation like Canada—and I might add that the United States and Australia are similar in that respect—require collaboration to unify things, such as common sources of information, such that the information doesn't vary from province to province and can be used by international graduates from outside of the country, who know that it's valid and applies across the board, to undertake credential verification--not such that an individual coming to Canada might need to apply to every province, but it could be done at a common place, at one time, paid for once, and then it could be available for others.

    To administer assessment processes for international medical graduates, that administration is sub-optimal, in the sense that more of it needs to be done before they come to Canada, such that they can be more quickly linked to positions or opportunities to further train or work.

    In that respect, previous immigration policies, we found, were disconnected from the reality of the primary payers or, you could call them, the buyers. In Canada, because of medicare and the Canada Health Act, in essence, we have what's called a monopsony, in the sense that there's one organization that sets the price with respect to who gets to practise and be paid. There's nothing wrong with that. It's something we did, but there is really no other mechanism.

    Also, with respect to training positions, the provinces decide how many training positions are there. If we're going to use the human capital model—which I support fully—and we have, we need to think about how we link that with the people who pay physicians to practise, or who pay for the educational processes, because in many instances that is limited.

    I'll come back to that point.

º  (1655)  

    The recommendations of the task force deal with many of these issues. There is a report, which I'll just hold up for you, and if any of you or your staff are interested in the website where you can obtain it, I have copies showing where to do that and I'll be glad to make them available to you through your staff here.

    The vast majority of people who undertake the credential process we have at the Medical Council and our examinations pass. Many don't, but most do. Of those who pass, often there's a need for further training—this is particularly true, if we're going to use the human capital model, where they may be partway through their post-graduate training—and the capacity currently isn't there to do it.

    In short, the payers or, if you like, the funders of physicians in practice—that's provincial health plans or regional councils—need to fund further training posts to enable the human capital model to work. That's an area I'd like to see this standing committee explore in more detail.

    My understanding, however, to give full credit where credit should be given, is that currently there is a five-department committee looking at how these things could be better coordinated, including Citizenship and Immigration Canada, Industry Canada, Health Canada, Human Resources and Skills Development Canada, and I think also possibly Foreign Affairs.

    One of the other points I'd like to emphasize is that because of this disconnect.... There is a chart in my handout that has a yellow and greenish graph. What I want you to appreciate is that if we look at the number of doctors in all provinces across Canada.... You have this chart; it is the first of the two charts in your handout. I want you to note that in green are shown doctors who come to Canada with prior arrangement of a position or appointment; the yellow shows those who come without prior arrangement.

    If you look at provinces such as Saskatchewan or Newfoundland, which are largely dependent on international medical graduates, the vast majority of people in those provinces—Manitoba as well—came to Canada with prior arrangement of employment. They are active, are connected professionally, and in all respects are getting integrated into the health service.

    If you look at Ontario—and to a lesser extent Quebec and B.C., where we're really talking about Montreal and Vancouver—the vast majority of physicians, particularly in Ontario, come without prior arrangement of employment. This is a problem, because those are the people we hear about and read about in the paper.

    I've provided you with another handout from an interview the Globe and Mail did with me and others where I talked about our having last year more than 800 doctors who met all the various requirements, including credentialing, but were unable to find further training posts because they don't exist in Canada. I would argue we need to think about those folks before we bring other doctors—not that we shouldn't bring other doctors, but I think there is a need to deal with this. That requires better coordination.

    From the point of view of my organization, which does what it's supposed to under our act, we provide the exams, and they pass, and then what do they do? In a sense, it's a dichotomy for us. I certainly have to defend those people who have passed our assessment processes.

    I would finish by reading my conclusions. I want to impress upon you our interest in collaborating and doing anything we can do to help, because that in fact is our role.

    The Medical Council of Canada is committed to working with partners to establish a national physician registry agency—and one of those partners is going to speak; she represents the organization called the Federation of Medical Regulatory Authorities of Canada—that all agencies can use. We're willing to consider how that model, if successful, can be extended to other professions as we learn from going through this experience.

    Secondly, the Medical Council is primed and ready to offer more services overseas to enable as much as possible the prior assessment of learning and credentials verification so that can be achieved in advance of consideration for employment opportunities in Canada, so that we don't end up with a group of people who are professionally isolated and disconnected from opportunity.

    Thirdly, the Medical Council is prepared and willing to participate in creating a national assessment consortium to establish infrastructural standards and assessment standards—here I'm talking about how we can use each other's processes rather than reinvent the wheel 13 or 14 times; perhaps I should say 13, given our current context—so that all international medical graduates can be assured not only of coordinated planning but also of internationally approved standards, which exist for how to run assessment processes, not to mention a more efficient use of existing infrastructure by all agencies concerned.

    Currently, as a result of the task force recommendation, there is funding from the federal government, which Dr. Fry announced in Calgary a month ago, where money is available to encourage these agencies to work together. We, with other partners, have committed to try to undertake some of these initiatives to ensure that happens, because in the end it's all about implementation. Talking isn't good enough.

»  (1700)  

    Finally, we would like to encourage the standing committee to emphasize the need for maximum collaboration amongst the various parties in Canada. Immigration and social integration of physicians or any other professionals are complex challenges, and this is particularly key in a profession where the public's protection and safety are of concern.

    I again want to thank you for the opportunity to speak with you. I'd be more than pleased to entertain any questions, criticisms, or suggestions of things we might think about that would be helpful to you in your deliberations. Thank you very much.

    The Chair: Thank you very much.

    Ms. Lefebvre, do you have a presentation?

[Translation]

    Mrs. Fleur-Ange Lefebvre (Executive Director, Federation of Medical Regulatory Authorities of Canada): Yes.

[English]

    The Chair: Thank you very much.

    Next is the Federation of Medical Regulatory Authorities of Canada.

    Bienvenue.

[Translation]

    Mrs. Fleur-Ange Lefebvre: Good day and thank you very much.

    The Federation of Medical Regulatory Authorities of Canada welcomes this opportunity to discuss with the Standing Committee the important issue of recognition of international credentials. My name is Fleur-Ange Lefebvre and I am the Executive Director and CEO of the Federation. I apologize to French-speaking members

[English]

as I will now continue in English. You do have copies of my presentation in both languages.

[Translation]

    Ms. Madeleine Dalphond-Guiral (Laval Centre, BQ): Francophone members are quite used to it.

    Mrs. Fleur-Ange Lefebvre: Perhaps I'll switch over to French at the mid-point of my presentation.

    Ms. Madeleine Dalphond-Guiral: So I guess I made my point.

[English]

    Mrs. Fleur-Ange Lefebvre: I would like to read my presentation to you because of the technical nature of the information it contains. I would not normally do this, but there are details in here that I think it is important to impart to the committee, and I don't want to miss any.

    FMRAC stands for the Federation of Medical Regulatory Authorities of Canada. We are a national structure for the provincial and territorial medical regulatory authorities. Together we present and pursue issues of common concern and interest, and we share, consider, and develop positions on such matters. Of course, regulation of the medical profession is a provincial and territorial mandate.

    The regulatory authorities are called boards or colleges and are statutory bodies established by provincial or territorial legislation. They exist to do a number of things: first and foremost, to protect the public; to maintain the standards and honour of the profession; to establish rules for the proper professional conduct of its member physicians; to determine qualifications for registration and licensure; and finally, to evaluate the competence and conduct necessary to maintain registration and licensure.

    The federation and its members recognize that self-regulation is a privilege granted to the regulatory authorities for the public good, and that they have a responsibility to merit the retention of this privilege.

    We thought it would be important, before talking about recognition of foreign credentials, to highlight for you how we recognize domestic credentials. Briefly, a physician who graduated from a Canadian medical school, did post-graduate medical training--otherwise known as residency--in Canada, and meets the other requirements for registration will be granted a regular licence in any of the provinces or territories.

    This means that in most circumstances, for a regular licence, the physician holds an MD degree, is a licentiate of the Medical Council of Canada, and is one of three things: a certificant of the College of Family Physicians of Canada, a fellow of the Royal College of Physicians of Canada, or a fellow of the Royal College of Surgeons, and has been found to be in good standing previously.

    The requirements after obtaining the MD degree, which is granted by a specific faculty of medicine, are national, with the exception of Quebec, which has its own exams for those physicians wishing to practise in that province. It's important to note that the medical profession has long recognized the value of national standards of competence and assessment, one of the benefits being the portability of eligibility of licensure across our vast country. Again, it is the portability of eligibility that is at stake. There is no such thing as a portable licence in Canada.

    These requirements represent the gold standard; however, each medical regulatory authority has the power within its own jurisdiction to make exceptions for valid reasons, the most common being to fulfill the health care needs of underserviced areas or populations.

    We will now move on the recognition of foreign credentials. This will take a little bit longer. A physician who has studied medicine and/or done a residency in a country other than Canada or the United States, and who wishes to come to Canada to practise medicine, must apply to a given jurisdiction for recognition of equivalence of credentials. Each of the provincial and territorial medical regulatory authorities has established procedures to do this.

    In most jurisdictions, the international medical graduate must first pass the Medical Council evaluating exam. As Dr. Dauphinee highlighted, this exam is specifically designed to evaluate those physicians with foreign credentials. This is followed by the MCC qualifying exam, part one. At this point we're moving into credentials that Canadian graduates of Canadian schools must also pass. Recognition of equivalence of the diploma in medicine may be granted at this point, and it is done so because an equivalent assessment of knowledge and skills has been passed.

    The next step is recognition of the residency or post-graduate training. This is the critical step in determining the available licensing options, because the safe practice of medicine depends not only on knowledge, but on the ability to apply that knowledge in real practice and to exercise judgment. These two skills are acquired during post-graduate training.

    There is considerable variation across the jurisdictions for this step, but they basically follow the same pattern. The candidate's file is reviewed to determine whether the acquired post-doctoral training is equivalent to that of family physicians or specialists recognized in that jurisdiction, in accordance with the regulations that apply in that jurisdiction.

    If the jurisdiction determines that the training is equivalent, this is usually followed by a period of direct observation in a clinical setting. The duration of this period can vary significantly from jurisdiction to jurisdiction and from specialty to specialty, because of varying practical considerations.

»  (1705)  

    At the end of the observation period, there are three options. First, it may be recommended that the physician apply to the College of Family Physicians of Canada or the Royal College of Physicians and Surgeons of Canada to take the appropriate certification exam. Whether they can sit that exam is a decision of these two bodies. Second, an additional period of direct observation or training may be required. Finally, it may be recognized that the gap between this physician's credentials and the standards for safe, independent medical practice in Canada is too wide, at which time the physician may be encouraged to apply to do a post-graduate program or residency in a given discipline.

    The second and third outcomes would be followed by the requirement to take the certification exam before being eligible to apply for full licensure.

    I'd like to talk now about restricted licences, because these are an important component of integrating IMGs into practice in Canada. Most physicians who have international medical credentials do not meet the requirements for full unrestricted licensure, and we grant that it's often because there has been insufficient evaluation of their ability to practise safely.

    Some jurisdictions, as has already been pointed out, notably Saskatchewan and Newfoundland, have historically relied to a great extent on the service of IMGs to fulfill the health care requirements of their populations. These and all other jurisdictions have the power to give restricted licences to these physicians. They are normally granted under the following conditions, and there are seven of them.

    To begin with, they are time limited, usually one year, and then they are renewable.

    Second, there is some degree of supervision during the tenure of the restricted licence, again to ensure public safety.

    Third, as has already been pointed out, the physician must hold an MD degree or equivalent from a school or university registered in the World Health Organization's directory of medical schools.

    Fourth, the physician must provide the necessary attestations, such as certificates and diplomas, demonstrating that the candidate interested in obtaining a restricted licence has completed the training necessary to acquire the competence in the area for which a licence is being sought.

    Fifth, the physician must provide proof of good standing with a competent authority and attestations that the physician is practising or has practised with competence the discipline concerned for a defined period and within a defined timeframe prior to the application. This will address the issue of physicians who have been out of practice for prolonged periods of time.

    Sixth, the physician must provide supporting evidence that his or her services meet an obvious need in a discipline or region and are required by an establishment and that the physician agrees to the contractual understanding of said region or establishment. An example of this would be that the physician has been recruited by that region or establishment.

    Finally, the physician must eventually pass the required examinations before becoming eligible for an unrestricted or full licence. This is usually done within a prescribed time period.

    If a physician who holds a restricted licence has his or her privileges withdrawn by an establishment or abandons practice before the expiry date of the licence, it's important to note that the licence will expire immediately. The act of converting a restricted licence into a regular licence to practise medicine is subject to the various regulations in each jurisdiction, the same as would apply to somebody who has graduated from the Canadian system.

    Again, it's important to emphasize that each medical regulatory authority has the power to make exceptions to the rule for valid reasons subject to its obligation to put in place controls to protect public safety.

    So where do we go from here?

    Yesterday you heard from Louise Sweatman, who is the chair of the Canadian Network of National Associations of Regulators. The Federation of Medical Regulatory Authorities of Canada is a member of that network, and as such, we have signed on to the principles that she presented to you yesterday.

    We're going to reinforce the message that Dr. Dauphinee has just made. The biggest challenge is one of capacity of the medical education enterprise in Canada. The assessment of international medical graduates is resource intensive, and it behooves governments, including the federal government, to provide these resources based on actual costs.

    We would like to emphasize that these costs, including development costs, should not be borne by the regulatory authorities. A nice comparison is that, after all, the regulatory authorities do not bear the cost of training and assessing domestic medical graduates.

    Another important point must be made. We must look at the system as a whole. As Canada grapples with the reality of an insufficient number of physicians to serve the needs of its population, the increases in undergraduate enrolment that occurred over the last few years must now be matched by increases in post-graduate or residency positions. As Dr. Dauphinee pointed out, the MD degree in Canada gets you nowhere. You must do a post-graduate training period in order to be eligible to obtain a licence.

»  (1710)  

    We already need to increase the number of slots for the graduating cohort. Add to that the necessary positions to evaluate appropriately and train the international medical graduates and you'll note that it is critical to inject financial resources into the system, but as we're doing that, it's also critical to note that that is not enough. With physician shortages all across the country, including in the academic health sciences centres, there will also be a shortage of clinical teachers. Careful thought must be given to addressing the issue of human as well as financial resources as the capacity of the system is expanded to accommodate both the qualified international medical graduates and the increase in graduating cohorts.

    The Federation of Medical Regulatory Authorities of Canada and most of the provincial and territorial medical regulatory authorities are on record as supporting the December 2003 recommendations of the Canadian Task Force on IMG Licensure. These recommendations were made to the Conference of Deputy Ministers of Health.

    The federation is intimately involved in implementing a number of these recommendations, working in close collaboration with the Medical Council of Canada. I don't want to go through the report, but it is important to underscore the willingness and eagerness of the medical profession to engage in the development of processes and products, both at the national and provincial-territorial levels, to facilitate the integration of qualified and safe international medical graduates into the Canadian health care system.

    We can't emphasize enough that the primary role of the medical regulatory authorities is to protect the public safety by ensuring that the physicians who provide health care services in their jurisdiction are competent to do so. The challenge we have is to balance this role with that of needing to fulfill the health care requirements of the population, especially in those jurisdictions with large rural and remote areas, or with special needs populations.

    Medical regulatory authorities have long worked to integrate, in an appropriate manner, qualified IMGs into the health care system, where they now represent a significant percentage of working medical practitioners, and we look forward to participating, with adequate support and resources, in the development of procedures and tools to facilitate more of this integration.

    Merci beaucoup.

    The Chair: Thank you very much.

    We're going to have questioning. We've got 40 minutes and we have four members, so 10 minutes maximum for each member. We rotate Conservative, Liberal, Bloc and Liberal.

    Mr. Hanger.

»  (1715)  

    Mr. Art Hanger (Calgary Northeast, CPC): Thank you, Mr. Chairman, and thank you both for your presentations.

    I have a question that hasn't really necessarily been addressed in any of your presentations here. I have a relative who obtained two engineering degrees and had been responsible for building a lot of laser equipment to assist doctors in their profession. He then went into medicine himself and obtained his medical degree--a very qualified individual, I dare say. But he then looked around this country to apply himself in the fullest. With all this training and his skill, he ended up south of the border in Nassau and is working in Nassau. I think he is probably one of many such individuals who have gone south.

    I'm kind of curious. We do have a physician shortage in the country, as you pointed out, but what are the numbers of doctors and highly skilled and trained people actually leaving Canada and going south or elsewhere? What numbers move every year?

    Mr. W. Dale Dauphinee: It varies from time to time. We've been in the situation pretty well over the last 10 or 15 years, except for a period in the mid-1990s, where in the range of 250 to 350 people a year would leave, but the repatriation rate would be around 250 a year. In other words, there's a net loss of dozens rather than hundreds.

    However, when we talk about social integration in context, during the mid-1990s, when the number of positions in Canadian medical schools was cut back by 10%, there was a report generated, known as the Barer-Stoddart report, which unfortunately got cherry-picked, as often happens, but clearly raised the issue that Canada may have too many physicians and was contributing to cost overruns, that one way to approach it was to curtail the number of physicians. During that time, we saw a big increase in the number of physicians leaving Canada, and many of them were young people.

    Part of the reason, I think--and these are subtle influences--is a “well, they don't want us here” type of attitude. At that time I was a professor at McGill University, and I can tell you that was a common story to hear, and I think there are times when it increases.

    On the other hand, I can also tell you that we saw it the other way during the Vietnam War. I've certainly worked with many colleagues over the years who came to Canada when they saw circumstances they didn't like.

    So I think the point to be made is that there clearly is a loss; there has been historically. On the other hand, many people come back.

    The thing we know is that if it's young people, the data is pretty clear that most of them will come back. They're usually going for training. I went to Johns Hopkins, for example, for some of my training, and I came back. If they are more than 10 or 12 years--that range--in practice and they go, they're not coming back, as a rule.

    So I think there are probably two pathways active here. There is a little group that monitors this. We haven't had our meeting this year to look at what the data is, but we'll probably be doing that in the next month or two. If you're interested in that, I can get that information to you when we report it, which should be within the next six or eight weeks.

    Mr. Art Hanger: The committee would be interested in the information, as well as probably the reasons behind most of the migration.

    I'm interested in your chart here also, of those who intend to practise medicine with or without arranged employment. For those numbers that reflect “with arranged employment”, who has established the criteria when it comes to those numbers, or are there criteria established, that we have a need, so we will send out word broadly for the country that we need x number of physicians, so they will be attracted or will apply? Who actually establishes that?

    Mr. W. Dale Dauphinee: There isn't a quota.

    I just visited Saskatchewan a week ago, and I was one of the people who did the visit to Newfoundland. What happens in provinces like Newfoundland and Saskatchewan is that, through the health ministry in that province, they look at where their needs are. They tend to go and look at countries whose training they are familiar with, and they seek individuals who they feel can meet those needs. Because both of those provinces recruit actively and have programs, many of the people come really in the context of a work permit, to fill a particular position in a particular place, and they take advantage of the licensing requirements that Dr. Lefebvre mentioned in terms of how they allow people to take time to get to their full qualification.

    But the point I was trying to make was that in those provinces, because they are dependent on international graduates, they go outside and seek in particular places.

    Many of the people in Ontario have often come on their own and without a lot of prior assessment. In many cases, they're older. I've certainly met people my age---and I'm not young any more--who've come quite late in life, with an expectation. On the other hand, many of them are in the prime of their career.

    The difficulty there is that if they don't have prior arrangement, it would appear from what we saw and the interviews we conducted--and I did meet and interview many of these people in Toronto--they end up going to a cultural community that is similar to their country.

    Years ago, most of those people came from the U.K., South Africa, Ireland--what you might expect for historical reasons. Many of these same countries now are in the same situation with respect to the fact that they need physicians. So individuals are coming from many, many other countries with which we are not as familiar and also the background preparation isn't as well known to us. So provinces like Manitoba, Saskatchewan, and Newfoundland tend to go to those places with which they are familiar and look for people.

    In the other case, individuals are essentially, I don't want to use the words “showing up”, but they are arriving in Canada without pre-arrangement. When that happens, that's a big disconnect. Everybody loses when that happens. We really have to do a better job at trying to make that collaboration, and it can be done.

    One of the things that can be done is probably to make as much as possible available to them overseas and try to manage expectations, but find out what their prior knowledge is. If we really are going to use the human capital model, there has to be some provision when they get here that they can expand their knowledge without being faced with quotas, because the quotas are at the level of post-graduate training posts.

    For example, we've had this great public health crisis, and now there's a push that maybe we need more people. Many of these people, with a fairly short course, could fill some of those roles, for example, but where do they go and who helps them pay for it?

»  (1720)  

    Mr. Art Hanger: Well, exactly. In my own riding I'm very much aware that there are a number of individuals who have actually had medical training elsewhere, but it's obvious that their qualifications or the standards under which they trained are not equivalent to anything in Canada. They seek to follow up that kind of training here, but there doesn't seem to be a provision.

    It's frustrating for them and it's frustrating even for me as it's being brought to my attention and I want to help them out in some fashion. But I'm very surprised to see the number of individuals who actually do come with some sort of medical degree without arranged employment. I didn't realize those numbers were that high; that's interesting to know.

    Thank you.

    Mr. W. Dale Dauphinee: If I may, there's one other comment I'd like to make. In 1975 I happened to be involved as a member of the Medical Council rather than as an employee. The Immigration Act was changed in 1975 such that medicine was no longer a preferred profession, which it had been before that time. At the time there was a concern that if they were going to limit access to Canada, there should be some processes to make sure the individuals who came had sufficient background that they could integrate fairly easily.

    At that time there was a coordinating--we then could use the word “manpower”, and I apologize for using it--committee that worked with that, but it seems that there was a collaboration such that, for example, these assessments could be done in Canadian embassies. External Affairs was involved in that. In fact, my understanding was that over twenty embassies were used around the world to help make assessment of whether this was the right person to invest in, if I could put it that way, if they required further training.

    That over time seems to have drifted apart, and we have a lot of stovepiping and silos. Part of what the task force said was that we had to get back to trying to do what we tried to do 25 years ago, and I think it can be done.

»  (1725)  

    The Chair: Can you make it very brief, 30 seconds?

    Mr. Art Hanger: It was going to be a comment, actually.

    I worked in northern Alberta as a young fellow in the 1960s, and there was an Irish doctor working there who couldn't wait to get to Canada. Being a student of history as well, he wanted to know and experience the north. They couldn't have placed him in a better place than a small town called Manning, Alberta. He just thrived in that environment and the people loved him as a result of it.

    I can't see why, even today, there would not be such individuals around the world with degrees who would be pretty compatible with what we have right now and who would probably appreciate such postings as well. That's just a thought.

    The Chair: Thanks, Mr. Hanger.

    Mr. Telegdi.

    Hon. Andrew Telegdi (Kitchener—Waterloo, Lib.): Thank you.

    You say these are the number of people who immigrated to Canada. Do you have a breakdown for how many of them were refugees, or do you classify them all the same?

    Mr. W. Dale Dauphinee: We don't divide them that way. I could not tell you how many of those were refugees. Somebody knows; unfortunately, I can't answer your question any better than that.

    Hon. Andrew Telegdi: The other question I have is on the cost of certification and how long it is good for.

    Mr. W. Dale Dauphinee: The cost of the initial steps for our exam would be in the range of $2,000. The initial assessment before that, including the review of credentials and an initial screening exam, would be another $1,000. With respect to people who want to go on and get their certification from either the College of Family Physicians or the Royal College, I don't have those figures at my fingertips, but we certainly can get them for you.

    Hon. Andrew Telegdi: I'm looking for the figure it takes before they are ready to go and do an internship.

    Mr. W. Dale Dauphinee: For that it would be the figure I gave you. The internship actually doesn't exist any more; it's now called a residency. During the residency--they do that before they do the Royal College--it's $635 for our part one and it's $1,200 for the clinical exam with standardized patients. For the assessment beforehand, if they do the evaluating exam including credential review--I'll round the figure off for those two things--it's $1,000.

    Hon. Andrew Telegdi: That's $3,000. How long is that good for once they...?

    Mr. W. Dale Dauphinee: Once that's done, from our point of view it's done and it's good forever. Now, there are other requirements that may be in place in terms of how you maintain your licence in the province.

    One of the things where we're interested in trying to get more efficiency and something the task force focused on--and here I'm wearing a task force hat--was that we'd like to see where people only have to apply to one place for the credential. For example, it's conceivable that if I were coming to Canada, I might apply for a credential in Ontario, Quebec, and Alberta. The way it is now, I would then have to pay each time. What we're pushing for is that there should be one agency and the price paid one time. That price varies greatly, from $750 in Ontario down to zero for the Northwest Territories.

    Hon. Andrew Telegdi: If you get accreditation and are ready for residency but can't find a residency position, does the accreditation run out at some point in time?

    Mr. W. Dale Dauphinee: If we've verified that they graduated from where they say they did and if they've passed the exams I talked about, that does not have to be renewed.

    Hon. Andrew Telegdi: Once it's done, it's done.

    Mr. W. Dale Dauphinee: It's done.

    Hon. Andrew Telegdi: Now look at these figures. My region, Waterloo region, is short about 50 physicians, and we are actually classified as an underserviced area. It boggles the mind that we'd be an underserviced area. We have more than 50 physicians who've passed the medical exams and they can't get residency. The local chamber is involved in trying to lure doctors with bonuses and what have you from other underserviced areas. It's nice having a doctor arrive, but when all of a sudden you find out they came from Kirkland Lake or someplace else, you know there is a problem up in that community.

    Is the reason we don't have enough residency spots to qualify these doctors because the provincial government realizes that every time they approve a new medical practitioner, it drives up the cost of delivering medicare?

»  (1730)  

    Mrs. Fleur-Ange Lefebvre: I think that would have been true, potentially, a little while ago. I think right now everybody is cognizant of the shortages, more and more so, and that is not the case.

    There is a significant cost to increasing the number of post-graduate training positions per se, and right now we have the philosophy in Canada that first and foremost our duties are to the graduating cohort. That is the way the Canadian Resident Matching Service runs its match right now. It runs it in two iterations--and you'll be hearing about this, I believe, later in your proceedings. The first iteration is reserved for Canadian graduates of Canadian schools who have never done post-graduate training, so even if they didn't graduate that year or the previous year, they can still get in. The second iteration is for the people who were unmatched in the first iteration and for other candidates, such as international medical graduates. That's a philosophy we have that's been in place for some time.

    The reason we have this philosophy is that we don't have enough positions. The reason people go to the States to train is that they have an amazing slush fund or a set of slush positions. They have capacity to train we do not have.

    You should know that the Canadian Medical Forum, which comprises nine national medical organizations including our two organizations, is really pushing again for something we recommended in 1999 to the Conference of Ministers of Health, and that is for 120 post-graduate training positions for every 100-person graduating chunk. That would leave 20 positions for every 100, so if we're graduating 2,000, we have 400 extra positions that would allow the flexibility to integrate these people into appropriate training positions.

    Often they don't have to be full post-graduate positions. Post-graduate training in Canada right now is a minimum of two years for family medicine, but it can go on upwards of seven years in one of the surgical specialities. If we had that, this problem would be a lot easier to solve; it is an issue of capacity.

    You also have to remember that they may have passed all their exams, but anybody looking at taking this candidate into a residency position or any medical regulatory authority looking at this candidate from a licensing perspective is going to look at the amount of time this person has been away from active practice. We spend a lot of money and a lot of resources on continuing medical education for physicians who have never been out of practice. You can extrapolate that for somebody who has been out of practice for a while and imagine the resources it would take to assess that person and potentially bring them up to speed.

    Hon. Andrew Telegdi: Doesn't the United States have excess training capacity?

    Mrs. Fleur-Ange Lefebvre: Yes, they do.

    Mr. W. Dale Dauphinee: I can comment on that.

    Through Medicaid and Medicare.... It's mainly through Medicare this is paid for. But essentially, for every 100 American graduates, they have 120 posts.

    In many ways, the procedure is tougher in the States, but it's simple to use. You know that you have to pass these exams, and if you get through, you've got a chance to demonstrate what you can do. That's true across the country. In fact, the capacity above and beyond what you graduate in your own country.... It is absolutely critical to manage this in an effective and efficient way.

    So that's the figure they use.

    Hon. Andrew Telegdi: Can I just wrap it up?

    Would it make sense then for somebody like the chamber, who's now spending money to bring in people from other underserviced areas, to use the money to take one of the people who want to live in our area and pay for their certification down in the States? It would mean that Kirkland Lake would get to keep their doctor, and we would have somebody who is now able to practise in Kitchener-Waterloo, or the Waterloo region, who is from our region?

    Mr. W. Dale Dauphinee: It's probably a workable strategy. The risk you'd run from doing it there is that they might not come back. I mean, you're right, but I think that's how you have to think about it and look at ways of doing it.

    The fact of the matter is that until we have that flexibility in capacity, there isn't going to be a chance to do it. We have to decide, if the human capital model is the model—and that's our official policy, which I support—it has to be matched on the other side where there is the opportunity for these people to do that.

    For example, there are silly things, such as that they often can't get loans like our own students can to cover them while they go through some of these processes, because they aren't Canadian graduates. You'll find our task force report interesting, as there are a lot of issues like this that we couldn't deal with. But there are things like that, which can be done. So in a sense, you're proposing that your own local area do that.

    I can tell you that about 15 years ago I was involved in a similar program supporting getting doctors into northern New Brunswick. We used a lot of other resources and were able to recruit people from the States successfully by providing the right environment, where they felt they were coming to a situation that was very interesting, in terms of how it was constructed, integrating care of the elderly with public and industrial health in an industrial town. But the initiative came from the town, working with the provincial government.

    To me, in provinces where there are regional councils, that's probably much easier to do. Ontario doesn't have that structure, but in essence, there's no reason why you can't recreate it.

    The risk of going to the States is that they may not come back.

»  (1735)  

    The Chair: Thank you very much.

    What would be a healthy ratio of doctors per 100,000 population?

    Mr. W. Dale Dauphinee: It would be 1.9 per 1,000.

    The Chair: So 1.9 or, say, two doctors per 1,000 population.

    Mrs. Fleur-Ange Lefebvre: The 1.9 versus the 2.0 is very important; that translates into a lot of doctors.

    The Chair: Per 1,000 population or 100,000?

    Mrs. Fleur-Ange Lefebvre: Per 1,000.

    The Chair: How about in the States? What's the ratio there?

    Mr. W. Dale Dauphinee: I don't know that off the top of my head. I think it's slightly higher; but again, as I offered to Mr. Hanger, I can get that information for you. I know where to get it and can provide it to you.

    The Chair: Is it possible that doctors themselves, say the Ontario Medical Association, want to protect the ratio to protect the economic situation of the current doctors? Is that the idea, or is there another explanation for it?

    The reason I say so is that they were advertising on TV last month that the Ontario Medical Association had increased their intern number from 100 to 200 all of a sudden. How could they do that now, while they couldn't do it last year?

    Mrs. Fleur-Ange Lefebvre: I think the situation is changing. People are realizing that the shortages are so severe right now.

    In the mid-nineties, as we had regionalization and health care reform sweeping across the country, I think people were hesitant to do anything major. This was during times when people were saying we needed to decrease enrolment and we needed to decrease the number of physicians in order to control budgets. Budgets were capped.

    It's interesting being a doctor in a situation where you have a capped budget, and all of a sudden somebody is saying we need an influx of physicians into the system. If your budget is capped, it means that your income is going to go down. In some instances, your capacity to use the system to help your patients is going to go down because you have a capped budget for services as well as for physicians' salaries.

    The Ontario Medical Association right now has got a major campaign out to say to the government, we need more doctors in most of Ontario's regions. It's unfortunate that it took shortages coming into urban areas to highlight the significant shortages that were already in the rural and remote areas.

    So I think that right now the attitude has swung completely the other way, and I know of no major jurisdiction saying they do not have a shortage.

    The Chair: Thank you.

    Madame Dalphond-Guiral, s'il vous plaît.

[Translation]

    Ms. Madeleine Dalphond-Guiral: Thank you, Mr. Chairman. I will nonetheless be asking my questions in French.

    Dr. Dauphinee, you mentioned that you recognized all medical schools listed with the World Health Organization. You also stated that there was no formal accreditation process in place. The names merely appear on a list.

    I'm wondering if an internationally recognized accreditation process might not speed up the process of granting a medical licence. I worked in a children's hospital for 40 years, that is between 1960 and 1993. It was obvious that many medical residents came to Canada from foreign countries to receive their training. I know that space was at a premium then and the situation is now even worse. There's really no place to assess competence in a clinical setting. It's a terrible situation because all provinces, not just Quebec, are lacking the funds to deliver care. Skilled individuals are needed to dispense care, whether it be doctors, caregivers, nurses, physiotherapists or others.

    I'd like to hear your views on the subject. I think all countries, and not just Canada, in need of skilled medical practitioners would stand to benefit from some kind of accreditation process. Do you know if the World Health Organization is currently looking into such a possibility?

»  (1740)  

[English]

    Mr. W. Dale Dauphinee: Thank you. That was a very good question.

    There are two groups that are currently looking at exactly what's being proposed here. The International Association of Medical Regulatory Authorities, which both of our organizations belong to, has a working group that I sit on along with Dr. André Jacques from Quebec. We're looking at a fast-track system whereupon individuals could apply for what we are going to call an international medical passport. That will say to physicians, if you'll waive certain requirements or protections--in other words, if you're willing to say whether there's any action against you pending, even though it hasn't been heard--and are prepared to reveal that kind of information so we can establish quite quickly that you're bona fide and well trained, you will be registered and given what's called an international medical passport. It could be used for anybody who wished to take temporary positions, do locum tenens, and that type of thing.

    The committee is currently working on that. We'll be meeting in Dublin to discuss it further in two weeks--a good place to meet, right, Irish graduate here.

    The other point I want to make is that within that group there is collaboration in trying to establish similar assessment processes that we could do for each other. We are currently having discussions with the Australians on whether we could do some of that assessment for them in some of our embassies in our countries, and vice versa. So the point I want to make is that's in place.

    Ironically, the Foundation for Advancement of International Medical Education and Research just yesterday sent a notice to all of us of a questionnaire that they intend to give to all medical schools around the world to try to establish exactly what you're talking about. Unfortunately, that's going to take awhile. But they've clearly heard the message from people like you and are acting on that. That organization is located in Philadelphia in the United States.

    I don't think I'd be telling any secrets if I said my wife is a member of that board. I will certainly tell her what you've said to me.

[Translation]

    Mrs. Fleur-Ange Lefebvre: You've raised an important point. Just as it's important not to examine international medical graduates separately from Canadian graduates, it's equally important to look at health care professionals as a whole. This is critically important because we each have a tendency to work alone.

    Ms. Madeleine Dalphond-Guiral: On looking at your chart, I observed that ironically, a significant number of those who come to the three most populous provinces in Canada basically have a job waiting for them.

    I'd like to know how long it takes, on average, for a medical practitioner who comes to Canada without having made any kind of previous arrangements to be granted a restricted licence. Because, when a physician stops practising... I haven't practised nursing for 10 years now, and I can tell you that I wouldn't go back to work in a hospital tomorrow, and neither would Hedy.

    Mrs. Fleur-Ange Lefebvre: I can't give you a specific answer. I can only tell you that it varies greatly from province to province. Some provinces are more in demand than others. Therefore, even in the case of restricted licences, it's important to ensure that the physician practises in a particular province or region.

    In the case of provinces such as Saskatchewan and Newfoundland, the process would be somewhat faster and the criteria for receiving a restricted licence less stringent than elsewhere. In Ontario, Quebec and British Columbia, the process is lengthier and more complex. International medical graduates face ever longer delays and increasingly unfavourable conditions between their arrival in Canada and the time they are granted a restricted licence.

»  (1745)  

    Ms. Madeleine Dalphond-Guiral: They become caught up in a vicious circle of sorts, because the longer they must wait, the more skills they lose. There's also the matter of integrating into a new society. When a person feels increasingly undervalued, it's difficult for that person to integrate. The situation is rather insidious. Out of respect for these individuals and their skills, it's critically important that professional bodies focus on this issue. However, they need to take a holistic approach, rather than focus solely on the professional body in question. This is true not only of physicians, but of many other professional orders as well. This is a matter of great concern to me.

    Is there anything else you'd like to add to that, Ms. Lefebvre?

    Mme Fleur-Ange Lefebvre: I'd like to stress that there are standards governing the practice of medicine in Canada. It would be nice to have a single set of standards. Already, given the existence of restricted licences, we're playing with these standards somewhat, but I don't think Canadians want us to take too harsh a stance on this matter. They want the services of a professional physician and they are not about to get overly upset by the fact that this individual does not have a certificate from the College of Family Physicians of Canada or from the Royal College of Physicians. However, they do want our assurances that this physician has been evaluated in accordance with the same standards that apply to Canadian medical graduates.

    Ms. Madeleine Dalphond-Guiral: I can appreciate that. However, I'm thinking here about certain remote towns and villages that don't have a doctor. Dr. Fry could comment on that, but sometimes, a qualified nurse is better than no physician at all.

    You mentioned the recommendations made to the Conference of Deputy Ministers of Health by the Canadian Task Force on IMG Licensure. Reading between the lines, I sensed that you did not wish to comment on these recommendations. In fact you stated: “This is not the time to go through this report”. I took this to mean—as you know, we're always interpreting comments—that you had no wish to comment.

    I'd like to know which aspects of the report you find especially interesting. I would imagine there are a few. Otherwise drafting reports of no interest would be a waste of time.

    Mme Fleur-Ange Lefebvre: The report and the task force are truly interesting. As I pointed out in my presentation, the medical regulatory authorities support the task force's recommendations. Frankly, I should let Dr. Dauphinee answer that question, since he co-chaired the task force. However, six very interesting recommendations were formulated.

[English]

    Mr. W. Dale Dauphinee: Taken in broad context, we identified that there are two issues with respect to the point you're making about the tragedy and the loss of human opportunity.

    One is trying to prevent the situation that allowed this distribution to occur. We are saying such things as the following.

    We need a common portal for web-based information for people overseas to learn about things. We need web-based self-assessment exams that they can take, where they get the answer, where they don't score it themselves and say that they really have it right. We need to be able to provide an assessment process overseas of a more comprehensive nature, if they want to proceed with that, along with the notion of getting their credentials assessed before they come.

    That was one sector of things to try to anticipate, so that we know what people's capabilities are before they come. It still needs to be matched up.

    For example, in my home town in Nova Scotia, when I was a youngster, all the doctors were local people who went away. Currently, two Irishmen and a lady from South Africa are the doctors there. The next town has one British doctor and is anxious to get some more. Those are communities that want to see those people.

    We need to be able to link up those communities with some process such that we are able to attract them. If we have trouble attracting them, at least in terms of the point that was made earlier, there needs to be an attempt made to support an educational program to help them get it, either through training slots or even a community sponsor. Certainly, we've seen that before.

    The second thing is on those who are here in Canada. The reason I included the piece from the Globe and Mail is that I'm not against more doctors coming, but I know, within those groups in Toronto—I'm not saying all of them—or within Montreal, there are many individuals who could fill some of those positions.

    One of the things we've asked is can we not create a means by which those people can advertise what their skills are, so they don't have to pay the cost of advertising in the Globe and Mail? Can we create a place where my home town of Shelburne, Nova Scotia, can go and look, and say that there's a doctor with this qualification and that qualification, we'll bring him in?

    One of the things we're recommending is that such a registry be created. It would be voluntary. A person wouldn't have to do it, but a person would be able to put in what their capabilities are, so that, in a sense, we could facilitate what you're talking about.

    There are those who have been out for a period of time. For example, I have not practised for ten years. There's no way I would go back, but I would have to pay for it myself. That's fine. I'm at a time in my life where I could do that. For these people, if they wanted to do that, they need breaks. I gave the example of being able to borrow money. We need ways to help them to reintegrate.

    The other thing is that for people on the task force, who themselves were international medical graduates, in the section that looked at the particular problem that you're raising, we deliberately had it chaired by an international medical graduate, a physician who's in British Columbia. One of the points he made is that social integration is many things. We need to create support systems, and those need to be developed locally for when a community goes to look for somebody.

    I give an example of when I was involved in recruiting people to Baie des Chaleurs, New Brunswick. The community did an all-out effort to find a house. A lot of things were done; it was a community effort. It was very successful. I can tell you that all those physicians, 15 years later, are still in that community.

    Those are some of the practical things that we suggested. They are all implementation steps. With the money that Dr. Fry announced when she met with us at our concluding conference in Calgary in the first part of March, a lot of those things can be done. Many of our organizations have applied, with other partners, to initiate those programs, where we'll make in-kind contributions but also take advantage of some federal dollars.

    But we still need the link with the people who have responsibility in the communities, either regional councils or provincial governments, to make sure we get the right people in the right place. That linkage still needs to be done, because it is a monopsony, as I said.

»  (1750)  

    The Chair: Thank you very much. Merci.

    Dr. Fry, please.

    Hon. Hedy Fry (Vancouver Centre, Lib.): Thank you very much.

    I'm going to ask you a question. It's mostly for the record, because I think I've heard some questions asked that we probably need to get very good answers for.

    There are two components here that I think need to be put on the table: not only do we need to have the money to pay for a residency, but we need to have the place for that residency to happen. So we need to look at how we create residency spots in hospitals and in areas where there aren't any at the moment. Then we need to get people to teach. All of that adds up to more than just somebody saying, I have money and I want to go in for a position.

    I wanted to ask, just for the record...let's take someone who, let us imagine, just came in from another country. If you wanted to do the accreditation piece, the credentialing to say that they have the equivalency, you'd say they need, for example, a one-year residency position. Let us say you can find them that one-year residency position. What would be the cost from start to finish to make that person ready to go out and practise as a fully registered physician, first, in family medicine; and second, in some sort of speciality, let's say orthopedics? What would that cost be?

    That's the first question. It's a question about the cost of the people shown in yellow here. How can we get them able to go out there and practise?

    The second question I want to ask is what do you think is the cost-effectiveness of taking those people and spending that money for one or two years to get them ready to practise versus training a Canadian to go into medical school, do their bachelor of science or arts, get into medical school, do that whole thing, which would take roughly eight years? What would that cost be? I think many people want to ask that question. Why aren't we training our own medical students, and why are we going to spend money to take a person and do a one-year with them that will cost us? I need a cost-effectiveness and timeliness breakdown on that.

    And finally, how do we get the system to work so that all these people shown in yellow here don't have people jumping over them to go to places like Manitoba and Saskatchewan, where they're getting people straight from South Africa, bringing them in, jumping them and giving them the temporary time-limited licences to practise in isolated and rural areas? They're jumping them over these people in the queue to get them in. That is a question that was asked, if you recall, at the meeting in Calgary. That's a question I want to ask. We should get the people here to move forward. How do we stop the queue jumping?

»  (1755)  

    Mrs. Fleur-Ange Lefebvre: I will start, and you can take the bit that I've decided to leave out.

    I'm going to take them in reverse order, if you don't mind. How do we get the system to work so that the people who are already here get opportunities, rather than having people recruited? We have areas in Canada in which you are never going to get somebody who is already here and is used to living in downtown Toronto to practise. That is the reality of our situation, unless we impose some kinds of disincentives. That has not worked in Canada, and it will never work in Canada. There are other places they can go outside of Canada. We want to keep our doctors in Canada.

    That has been the attraction of international medical graduates for Canada and of Canada for international medical graduates. In many circumstances, the recruitment occurs because it has not been possible to recruit a Canadian grad or even an IMG who may not be practising but is well ensconced within their community in a bigger city, a metropolitan area.

    So I think it's not an either/or situation. We may be dealing with a bit of a blend.

    The cost-effectiveness issue is an interesting one. We haven't been dealing with it as a cost-effectiveness issue so much, even though somebody would tell you if you take somebody who has already had their undergraduate degree and a fair amount of post-grad, and you're looking at assessing them for a while, then you may be injecting some funds for a year, maybe a year and a half. Even if they have to do a four-year residency, it's still cheaper than putting somebody into the system from the word go.

    Hon. Hedy Fry: Don't forget to tell me the cost of that, just to put it out there.

    Mrs. Fleur-Ange Lefebvre: That's the third question, right: what's the cost?

    However, every organization that's a member of the Canadian Medical Forum has bought into the policy of self-sufficiency. We should strive for reasonable self-sufficiency in Canada for our physician requirements.

    There is the human rights issue, though. We have these people who are already here, we have people who want to come into Canada, and we have people who may be coming in as a physician because they're accompanying some other professional who is coming to Canada. We need to balance the cost-effectiveness of that with the human rights issue. I think, again, we will never be able to go full direction--okay, let's not increase enrolment, let's just recruit physicians from offshore. Again, there's an ethical issue about recruiting physicians offshore that is very real.

    So as we strive for self-sufficiency in the production of physicians to service Canadians, we need to keep in mind the need to have a capacity to train IMGs.

    The overall issue of the money for the slots--the place for the residencies, the teachers for the residents--is an issue we are facing right now. However, it is a blip. Well no, it's bigger than a blip; it's a significant bump. Once we get over that bump, we will have the system in place. What we have to be careful to do is not set up a system whereby we have all this capacity that we're not going to be using in 10 or 15 years. We have to really calculate that.

    I have not done a detailed analysis of the figures. The figure I do use is $100,000 per IMG. Now, if they go into a more significantly prolonged residency, then they are now covered under the residency--for the money. For the assessment, getting an IMG in place, I just use $100,000.

    Hon. Hedy Fry: I'm sorry, Dale.

    Mr. W. Dale Dauphinee: I just wanted to comment that in part, if you said it was $50,000 a year--I'm taking a figure, because what the salary is varies from province to province--and you're trying to come up with a figure for the infrastructural cost, I think $100,000 probably is not a bad ballpark to start with, and the fees would come out to about $6,000. Again, I've rounded that off.

    One of the points I wanted to make is, as we think about things, we need to sometimes think a little bit out of the box. I want to use an example, and this is not a criticism as much as a way we could think about things. This is particularly with respect to Northern Ontario Medical School. It's interesting that they're starting a medical school there. One could have considered, for example, starting it as a post-graduate school first, where you bring in international graduates and others, put them through the residency, and hope you retain them. They then become the teachers for the Canadians you're going to bring in a year or two later.

    I think it's unfortunate that didn't happen. That's a good example where those people are in Ontario--B.C., I know, is trying to do some of those things, although their numbers are smaller--where perhaps it was a missed opportunity. So we're starting from scratch with students in first-year medicine, and it's going to take between 7 and 11 years. The experience internationally in these things is that you don't see the output probably, for a specialist, for 12 to 13 years, and for a primary care family physician, you can probably see it within 10 years.

    It's an opportunity that, with all these folks, these people in yellow...it's too bad that we weren't able to take advantage of that situation, because it was a one-time event, and then it would have been a nice way to think about it. Unfortunately, it didn't happen that way.

¼  (1800)  

    Hon. Hedy Fry: May I have just one quick question?

    The Chair: Andrew has a 30-second question. Make the answer short, please.

    Andrew, you have 30 seconds.

    Hon. Andrew Telegdi: As for the people in yellow, I have a couple; he's a surgeon and she's a dentist. They're managing an apartment building and they would love to go any place in Canada.

    But I'm having trouble with the concept of self-sufficiency, and I'll tell you why. If we were to train two doctors per 1,000 population, some of those are going to take off and go someplace else. So it seems to me it's only fair that to offset that, we have a system where we can take in people who land on our shores. So if we can get a process in place to make that happen.... But in the short term, I would like to get some figures, if you would help us with that, on what would it cost us, in the U.S. and that kind of stuff, to train people?

    The Chair: Dr. Fry, make it very short, please.

    Hon. Hedy Fry: I think, in an infrastructure in which you have extra residency positions.... Let's say we are suddenly filled, that we all have 1.9 per 1,000 and everybody's happy and we have enough physicians. It might be useful, because the United States has been doing it, to have the extra residency spots. Then we could bring in foreign graduates to do residency here and go back to their home places. But we have those spots as we go into the cycle again of needing more physicians. They're always open for us. They're there when we need them, and yet we could make money on them in the meantime by bringing in international medical graduates to do residency and go back home.

    I think it would make sense rather than going into the cycles in which we have gone, in which we're boom or bust on everything we do and then we're scrambling to find the numbers that we need.

    The Chair: Thank you very much.

    Before we go, I wish everybody a happy Easter. To politicians in the room, good luck if there is an election before we come back—just in case.

    Thank you very much again. Happy Easter.

    The meeting is adjourned.