As part of its efforts to address the severe shortage of nurses and doctors in the province, the Ontario government has asked colleges of nurses and doctors to streamline entry requirements for trained professionals abroad.
It’s the right choice.
Professional regulatory bodies are creatures of provincial legislatures. Self-regulation by the professions is the backbone of our system, but the public interest demands that supreme authority rest with democratically elected officials.
Never waste a crisis, the saying goes, and as we slowly emerge from the seventh wave of the pandemic, severe shortages of medical personnel have shone a spotlight on overdue reform.
Many of the rules governing accreditation and equivalencies between Canadian and foreign graduates are archaic, based on preconceived notions and in serious need of objective overhaul.
Prior to the French leadership debate, professional regulatory bodies were high on the list of caretakers Pierre Polièvre planned to hire.
Of course, professional regulation is first and foremost a provincial jurisdiction. If Poilievre didn’t know before the Quebec debate, his own handlers (dare I say: gatekeepers?) clearly knew and he backed down from his more strident posture.
Now, he said, he would work with the provinces to help reduce barriers. That too is a good idea.
Poilievre was right to make this concession to constitutional reality, but the validity of his central point became apparent when the Ontario government issued its recent guidelines.
THIS IS PUBLIC PROTECTION
There is nothing new in this debate. There’s a joke in Quebec (where over a million people don’t have a family doctor) that the best way to see a doctor is to take a cab. Chances are the driver is a foreign-trained doctor.
I was president of the regulatory body that oversees all professions in Quebec. The same debates took place then and, in the meantime, much effort has been made to develop objective means of evaluating training and determining the equivalence of diplomas.
The bottom line is that this is for the protection of the public, so no shortcuts that could compromise safety should be allowed, even if there is a shortage.
At the same time, training standards are becoming more harmonized and although safety is the main concern, there are still a lot of institutional biases in the evaluation of internationally trained healthcare professionals.
DO NOT PENALIZE FOREIGN GRADUATES
We tend to forget that professional regulation is not just about entering a profession. It also involves inspecting and supervising professionals once admitted. A whole disciplinary process covers the system to ensure respect for patients, standards of practice and rules of ethics.
Yes, we should supervise all professionals. No, we should not penalize foreign graduates by suggesting that letting them in exposes the public to greater harm. They will be subject to the same rigorous supervision as all other members of the profession.
I remember a heated discussion between one of our regulatory agency officers and a senior player from the College of Physicians. This revolved around the quality of foreign graduates and their training.
My colleague asked a simple question: if you are traveling to Europe and have a heart attack, will you refuse treatment at a local hospital? The answer, of course, was no. Why then all these obstacles to the integration of these same doctors who choose to settle here?
There are arguments related to accreditation: could letting in foreign practitioners dilute the overall assessment of Canadian graduates and hurt their chances of obtaining a license in the United States, for example?
These issues are easy to fix and should not be used as a shield to prevent international graduates from helping to provide the health care Canadians need and deserve.
Like Canada, in the United States, professional regulation is considered to be the responsibility of individual states: a subset of their policing and licensing powers. They continue to have many barriers to obtaining interstate credentialing and professional recognition.
Here in Canada, we have done a decent job of facilitating inter-provincial recognition of professionals, although some unnecessary barriers remain here as well.
I was the first Canadian elected to the Board of Directors of the Council on Licensure, Enforcement and Regulation in the United States
This was shortly after the signing of the original NAFTA. This treaty had the effect of reducing barriers to professional mobility between Canada and the United States. The only restrictions allowed henceforth should be skill-based. Clearly and transparently.
WHAT WE NEED IN CANADA
Many states still had rules that required you to have passed your licensing exam in the state where you wanted to practice. For example, at the time, a pharmacist in New York had to be physically seated in Florida when taking the licensing exam, if he hoped to practice there. It had everything to do with protecting Florida pharmacists from competition and nothing to do with protecting the public.
Many of these hard-core interstate rules were swept aside by an international agreement that required an objective examination of the reason for the restrictions. If a requirement was not about competence and protection of the public, how could it be maintained?
It is this type of objective analysis of restrictions and preconditions that we need here in Canada now.
A second set of professional barriers should be under this objective microscope at this time: the rules of scope of practice between the various health professions. The line between what a professional can do and what requires membership in another profession is often stretched and can compromise the ability to do the only thing that matters: help the patient.
My brother and I spent much of the weekend with our mother in the emergency department of a small regional hospital. The care was excellent, but at one point the doctor said he would have to wait another hour before he could stitch up the leg my mother had injured in her nursing home.
The LPN assisting her explained that she had the right to install a type of tubing and inject such a substance but not such a drug. This required an RN and none were available. The clock was ticking because the stitches had to be inserted within a certain time after the accident.
Everything went well in the end result, but the question that came to me was: is this barrier between professions really, objectively necessary? Or is it a remnant of past arbitrations between professional orders?
We should take advantage of the current context to urge governments and professional bodies to work together to:
- Reduce barriers to recognition of foreign professionals;
- Develop objective ways to assess credentials and experience.
- Review restrictions between professions to improve care.
Tom Mulcair was the leader of the federal New Democratic Party of Canada between 2012 and 2017