An essential bridge to Canadian licensure

Canada depends on international medical graduates (IMGs), particularly in family medicine and within rural and remote communities. In 2019, IMGs composed an average of 25% of the physician workforce across the country; in Saskatchewan and Newfoundland and Labrador, that number was 50% and 40%, respectively; while in rural Saskatchewan it jumped to 70%.

In today’s context of a health care system under strain, and with many in Canada lacking access to a family physician, the Practice-Ready Assessment (PRA) is one route that can help alleviate those health human resource challenges. Seven provinces in Canada participate in a PRA framework called the National Assessment Collaboration (NAC), overseen by the Medical Council of Canada (MCC).

The NAC PRA pathway

The NAC PRA is an alternative pathway to licensure for IMGs who have completed residencies and practiced independently outside of Canada. For 12 weeks, under the supervision of trained physician assessors, a PRA candidate’s skills are observed and assessed in real clinical settings for readiness to practice within Canada. After completion of the rigorous assessment, successful candidates obtain provisional licensure, and most are fully licensed within two years. Dr. Jack Burak, clinical director of Practice-Ready Assessment—Physicians for British Columbia (PRA-BC) says, “If they pass our robust assessment, we have total confidence that they will practice safely and confidently. And if they decide to move across the country once they have their full license, the medical regulatory authority in whatever jurisdiction they move to will have that same comfort.”

The NAC PRA outlines a set of common standards for assessing IMGs. Clinical Director of the Nova Scotia Practice-Ready Assessment Program (NSPRAP) Dr. Fiona Bergin, established her program using the national framework and drawing on the existing provincial programs that, she explains, “are collaborative and helpful to each other, sharing both expertise and information.” The provincial programs rely on the MCC’s examinations to identify qualified candidates. These programs use the common tools, resources, and assessor training developed by the MCC and NAC. One of these resources is the Communication and Cultural Competence orientation program housed on physiciansapply.ca, a self-education program that helps physicians learn about the cultural expectations and communication standards between patients and physicians, and among health professionals. The latest module added to the program is “Compassionate Virtual Care.”

Why is PRA necessary?

The common conditions physicians see in Canada are often related to an aging population, chronic diseases, and the country’s unique population groups including Indigenous peoples, and might not reflect the common conditions seen in an IMG’s home country. Dr. Jon Witt, program director of the Saskatchewan International Physician Practice Assessment (SIPPA), explains that there is a bridging of knowledge and skills that needs to happen to support an IMG’s transition into Canadian practice and ensure patient safety. “During the 12-week clinical field assessment, assessment is going on, but learning is also going on. A broken ankle is the same across the world, but how you investigate it, how you communicate to patients, what follow-up would be done, how you communicate to other members of the team, the medications you would use—those are different.” It is essential that PRA candidates demonstrate knowledge of appropriate therapeutic strategies when managing medical conditions in a Canadian context while meeting patient expectations of a high standard of care. Importantly, as Dr. Burak clarifies, PRAs are “not retraining.” PRA programs identify qualified candidates and discover through assessment whether they are competent and safe to practice in the Canadian context.

Recruiting physician assessors

A shared challenge of the PRA programs is the recruitment of physician assessors. It is also the most limiting factor in expanding PRA program participant numbers. Many demands have been placed on physicians during the pandemic; the same diminishing pool of physicians are caring for patients while acting as teachers and supervisors to medical learners in the Canadian streams. Often, it is other IMGs who step up. Dr. Witt says, “They understand the immigration journey. A lot of them have trained in the same country, sometimes even the same medical school, as the applicants coming through.” Many physician assessors have come through PRAs themselves and see becoming an assessor as a way to give back. Dr. Bergin adds, “There’s a real feeling of kinship.”

At the end of each 12-week intake, new family physicians enter practice, joining communities where they are desperately needed. Dr. Bergin hears frequent praise for the PRA candidates from both physician assessors and patients. “They’re being well received in their communities and are doing well out there.” The NAC PRA assisted approximately 600 family physicians in entering the Canadian health workforce in the last five years; at approximately 120 physicians annually, it is comparable with a typical Canadian medical school.

In good news, existing NAC PRA programs have recommitted to the framework for another three to five years. Dr. Burak believes that “if the IMG pool of applicants is large enough, there should be the potential to expand all of the programs across the country.” The NAC PRA is making a notable contribution to the physician workforce and offers an essential bridge for IMGs to follow their calling in Canada.

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Dr. Viren Naik,
Chief Assessment Officer, Medical Council of Canada