Physician support and recent moves by provincial and territorial governments suggest that pan-Canadian medical licensure could be on the road to implementation, according to a recent statement and a poll from the Canadian Medical Association (CMA).
In Canada, health systems are regulated by individual provinces and territories, and medical practice is restricted to the province or territory in which a physician is licensed. In most cases, practicing in a different province or territory requires a lengthy application process and thousands of dollars in fees.
The CMA defines pan-Canadian licensure as "the ability for physicians with full licenses to practice independently without restrictions or for medical resident trainees registered in any Canadian jurisdiction to practice or train in any other Canadian jurisdiction without having to acquire more than one license or pay additional licensing fees."
"We know that the system is changing and that the door will continue to swing open wider, moving toward the inevitability of national license," CMA President Alika Lafontaine, MD, told Medscape Medical News.
Ninety-five percent of physicians support a national licensing system, according to a CMA survey released on January 30. In addition, Atlantic premiers announced on February 20 that a new regional registry will become available by May and allow physicians to work in provinces other than where they are licensed. Furthermore, Ontario has introduced legislation that will allow credentialed health professionals registered anywhere in Canada to work in that province.
"In Alberta, where I practice, it's already very common for folks in British Columbia, Northwest Territories, and the Yukon to share patients and move around," Lafontaine said. "I do think we'll see a convergence of all these trends.
"Patients have been a big driver in all of this," he added, "as access to care is the biggest issue for them right now. They want virtual care. They want to be able to have teams follow them wherever they go. If a person who lives in rural Quebec, for example, leaves to go to school in Ontario, a regional or national license would enable them to keep their family physician, which likely is not possible now because the physician probably is not licensed in Ontario."
Benefits and Challenges
The CMA believes a single licensing system would help alleviate pressure on the medical workforce in rural and remote communities by making physicians more mobile. That mobility could also support physician work–life balance, potentially improving retention rates and making it easier for physicians and hospitals to fill locums for holidays and parental leave.
Boris Kralj, PhD, an adjunct professor of economics at McMaster University in Hamilton, Ontario, Canada, and a member of the Centre for Health Economics & Policy Analysis, agrees with the CMA. Kralj, who coauthored a recent paper on physician workforce planning, told Medscape Medical News that national licensure would also eliminate the "onerous administrative process," which is a "major obstacle, particularly for young and early practice physicians." Eliminating the burden, he said, "would be beneficial to physicians and patients."
Some stakeholders are concerned that improved physician mobility "could hurt already underserved rural areas if some of their physicians leave for other more urban opportunities," he said. "I don't think this is a major issue, as rural physicians are a small and unique group and in rural practice for the many benefits it offers to them. I think rural areas are more likely to benefit by making it easier for younger physicians from other provinces to try rural practice, for example, via a locum placement. Some of them will stay in rural practice."
Furthermore, Kralj added, while national licensure would not offer more spots for internationally trained physicians, "it would make Canada a more attractive country for international graduates to try to locate to, knowing they would have freedom to move anywhere within the country."
Nevertheless, pan-licensure "would require a systemic change in terms of leadership and modernization of processes, and the Canadian healthcare system is very rigid, and such change is typically slow to occur," said Kralj. "There are very different and complex regulatory environments and requirements across provinces, and changing to a uniform standard is difficult. However, it can be done in steps, with incremental changes, and at least we could begin to ease the situation."
Tom Noseworthy, MD, academic director of the Centre for Health Policy at the University of Calgary, Alberta, Canada, told Medscape Medical News that national licensure "is long overdue." However, he raised a concern about itinerant service provision. "For instance, an orthopedic surgeon flies into a northern community, does a dozen cases, and leaves again without appropriate follow-up provisions. This will complicate manpower planning in provinces if there is a large cohort of mobile physicians unattached to any healthcare system."
He also is not convinced that national licensure will have an appreciable effect on physician shortages. "It will do nothing for primary care other than increase some locum activity in the north, which may be beneficial. Where it might help is in highly specialized services for which the physician can travel — for example, cardiovascular surgery coming from Halifax to St John's. So, while it may fix specific needs in specific places, it will do little to deal with the overall shortages."
Lafontaine acknowledged the challenges and potential pitfalls. "We all recognize that it's a difficult task to consolidate and realign the way that we regulate and license folks across the country," he said. "But it's not an insurmountable task."
In 2010, Australia adopted national licensure for a wide range of healthcare practitioners, and the consensus is that the system is working and could serve as a model for Canada, Lafontaine said. The CMA summarizes the approach: "Each profession has a national board which regulates and registers practitioners and develops standards, codes, and guidelines. This approach ensures standardized high-level medical competence and quality of care while making it easier for health professionals to work across different states — in person and virtually." The system has led to "significant improvements" in mobility, patient safety, and better data for workforce planning.
National licensure would require treating the physician workforce "Canada-wide, rather than just province-wide, which means rethinking training and distribution and how we will incentivize people to work in different areas and what keeps them there," said Lafontaine.
"Sometimes the assumption is that providers work in a market model, where we will migrate to where we get paid the most," he noted. "That's not necessarily true. There are reasons why we stay rural or remote or mobile. As we implement national licensure, I think we're going to get a deeper understanding of our workforce because we'll be asking different questions. And, of course, the practice of medicine will change quite a bit."
Lafontaine, Kralj, and Noseworthy have reported no relevant financial relationships.
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Image 1: Canadian Medical Association
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Cite this: Has the Time Come for National Medical Licensure in Canada? - Medscape - Mar 20, 2023.