Speech from the Throne
Motion for Address in Reply--Debate Continued
October 24, 2024
Honourable senators, this item stands adjourned in the name of the Honourable Senator Plett, and I ask for leave of the Senate that following today’s interventions, the balance of his time to speak to this item be reserved.
Is leave granted?
So ordered.
Honourable senators, I rise to speak on the Speech from the Throne to address an urgent need for Canada. Canada is facing a primary health care crisis, and the government stated in its Speech from the Throne that “To build a healthy future, we must also strengthen our healthcare system and public health supports for all Canadians . . .”
Yet an alarming 6.5 million people do not have access to a family physician, a number that is projected to rise to 10 million within the next decade. We find ourselves lagging behind our international counterparts, ranking last among 10 high-income countries when it comes to access to primary care. This is not just a statistic but a clear and present danger.
The shortage of family doctors in Canada is acute, and it is worsening, driven by a complex interplay of factors. Many provincial governments have hacked away at services and budgets and incrementally privatized health care, which has eroded the public system. Our population is growing and aging, yet we face significant administrative challenges and underfunded residency programs. Compounding these issues, fewer medical graduates are choosing to enter primary care. If we do not take decisive action, Canada is on course to experience a shortfall of 50,000 family doctors by 2031.
This looming crisis threatens to strain our health care system, leading to longer wait times and deteriorating health outcomes, especially in rural, underfunded and underserved communities.
Currently, about 1,500 residents complete their family medicine residencies every year. This number is woefully inadequate to meet the growing demand.
While the recent addition of 5 new medical schools, bringing our total from 17 to 22, holds promise for the future, we must recognize that building new schools and graduating new students is a lengthy and costly process. The first cohorts from these new schools will not graduate until the 2030s. Even then, merely increasing the number of graduates will not suffice. Without a corresponding increase in residency positions, we will not see an influx of new family physicians.
The federal government has been making efforts to tackle these challenges. The federal budgets for 2023 and 2024 outline a significant investment of $200 billion aimed at improving health care for Canadians. However, despite this increase in funding, we still lack workable timely solutions to address our immediate needs.
In light of these challenges, along with my colleagues who are both doctors, Senator Kutcher and Senator Ravalia, we offer solutions in a report called Maximizing Medical Talent: How Canada can increase the supply of family doctors by 50% quickly and cost-effectively.
Our report offers two crucial solutions that would make a meaningful difference in the short term. Canada has a wealth of trained doctors ready to address gaps in our health care system, but many are unable to practise due to a shortage of residency spots and limited capacity for Practice-Ready Assessments.
Currently, only 39% of international medical graduates are matched to residency programs on their first attempt, and just 18% on the next. These are graduates of overseas medical programs. They may be Canadians. They may be immigrants who have come to Canada. But they have passed all the exams required to determine that their training is on par with that of Canadian students graduating from Canadian medical faculties. Their training has been assessed through two exams. They have passed all the language tests. Many bring extensive clinical experience with them. Yet, close to 45% of them are left outside the tent. Instead of picking this low-hanging fruit, we are letting it lie fallow on the ground.
While health care is primarily managed at the provincial level, our proposals present a unique opportunity for the federal government to take the lead. First, we must increase residency spots for internationally trained medical graduates. Second, we must expand the existing Practice-Ready Assessment framework into a robust national framework.
We believe, colleagues, that these are viable pathways of federal initiatives aimed at significantly increasing the number of family doctors across the country. By leveraging federal resources, we can implement strategies that directly address the shortage in family medicine, ensuring that Canadians have better access to primary care. The time for action and innovative solutions is now. Thank you.
Honourable senators, I rise today to respond to the Speech from the Throne, which focused on strengthening Canada’s economy and building a more resilient and inclusive future. At the heart of this resilience lies our health care system, and today Canada is facing a health care crisis that is deeply intertwined with the well-being of our economy and society.
Today’s report from the Canadian Institute for Health Information shows that over 5 million Canadians do not have access to a family doctor, and this number is projected to reach 10 million within the next decade.
Consider this situation: An individual with high blood pressure or diabetes needs their routine prescription renewed. But without a family doctor or primary care provider, they end up in the emergency room, and after waiting for hours — and I have evidence that in some instances this may be as long as 16 hours — they finally see a doctor, who renews their prescription.
The irony? That emergency room visit, which could have been easily avoided, costs the health care system hundreds of dollars and adds considerable stress and a wasted day for the individual concerned.
This is the reality when millions of Canadians do not have access to primary care. Routine, non-urgent issues overwhelm our emergency rooms, making the system more expensive and less efficient for all concerned.
This shortage is not just a health care issue; it is an economic one. A healthy population is essential for a thriving economy. Canadians need timely access to primary care to reduce the strain on emergency rooms, keep people healthy and ensure they can fully contribute to society.
As a family physician, I’ve witnessed first-hand the critical role that primary care plays in the health and well-being of Canadians. Yet, we are at a crossroads. We currently rank in the basement of the high-income countries with respect to access to primary care. This is unacceptable for a country as prosperous and resourceful as ours.
At the same time, thousands of highly trained immigrant doctors and Canadians studying abroad in jurisdictions like Ireland, Australia and the Caribbean, eager to contribute to our health care system, are being handicapped and held back by systemic barriers, such as the limited number of residency training positions and insufficient Practice-Ready Assessment programs. These barriers prevent our health care system from tapping into much-needed talent and waste the potential of these physicians, who bring with them a wealth of clinical experience and, in some instances, global expertise that would be particularly valuable to our immigrant population.
My hope is that despite the government’s recent changes in immigration, a commitment to immigration of highly skilled individuals will continue in this country.
Alongside my colleagues Senator Omidvar and Senator Kutcher, after much debate, we released a report entitled Maximizing Medical Talent: How Canada can increase the supply of family doctors by 50% quickly and cost-effectively. It offers actionable solutions that align with the government’s broader vision of an inclusive and resilient economy.
The report presents two key recommendations to address the shortage by unlocking the potential of physicians from immigrant backgrounds and those who have studied abroad.
First, we must increase the number of residency positions by funding 750 additional family medicine residency spots annually. This would add 6,000 new family doctors over the next decade — doctors who are ready, willing and able to provide care to Canadians, especially those in underserved communities.
Second, we must expand Practice-Ready Assessment programs, which allow internationally trained doctors to demonstrate their competence and practice in Canada without the need for years of additional training. With a relatively modest federal investment of $70 million, we could add at least 1,000 additional family doctors annually through this program.
Addressing the family doctor shortage will reduce health care costs, improve the quality of life for Canadians and bolster our economy by ensuring a healthy, productive population. Moreover, these measures align with the government’s emphasis on inclusivity by unlocking the potential of immigrant professionals who have long been sidelined.
In this context, I want to acknowledge the federal government’s historic $200-billion investment in health care over the next 10 years. This investment is a vital step forward in addressing critical health care challenges, including the health care workforce crisis. It includes $46.2 billion in new funding, with a substantial portion aimed at health care workforce planning and retention, a key component to the family doctor shortage.
Additionally, $25 billion will be distributed through bilateral agreements with provinces and territories, ensuring that local health care needs — particularly of our rural, remote and Indigenous populations — are appropriately addressed. This investment prioritizes increasing access to primary care services, reducing wait times and supporting mental health initiatives, all of which are essential in building a resilient health care system.
However, to face this challenge head-on, we must act swiftly and strategically to ensure that talented health care professionals can fully participate in our health care system. This means leveraging the government’s investment to expand residency spots, growing the Practice-Ready Assessment, or PRA, programs and ensuring that every community, especially those in underserved areas, benefits from a robust primary care network.
I believe we are at a pivotal moment in Canadian health care. The family doctor shortage is growing more urgent by the day, especially in rural and remote communities where access to care is most limited.
With the solutions outlined in our plan, coupled with the federal government’s investment in health care, we hope we can make an immediate and profound impact. This is about more than just health care policy; it is about ensuring that all communities have access to care.
By removing barriers for these physicians, we not only strengthen our health care system but also enhance our economy and the well-being of society as a whole.
Together, we can build a health care system that reflects our Canadian values of inclusivity, resilience and opportunity — a system that meets the needs of all Canadians. In the meantime, colleagues, please be assured that I am happy to continue providing prescriptions to my respected colleagues.
Thank you, meegwetch.
Would the senator take a question?
Thank you, senators, for your report.
Senator Ravalia, can you expand on why the report talks about two routes? One is increasing residency spots: Have you had conversations with the universities and colleges that would organize those spots?
Second, can you speak to the Practice-Ready Assessments? As you know, as physicians, we are licensed and regulated by provincial colleges, and that falls under provincial jurisdiction. Different provincial regulatory authorities have Practice-Ready Assessment programs. Why both routes, and why not one versus the other?
Thank you very much, Senator Osler, for your very insightful question.
The residency training program would be aimed, in particular, at those physicians who have just completed their training, particularly those Canadians studying abroad who need a base training pathway to enter the system.
As you know, we have upwards of 4,000 young Canadians studying abroad who are anxious to return. In the current system, only a small handful ever get into our programs. The majority end up, unfortunately, in the United States where they settle, never to come home. This is a very fertile, valuable resource that we are missing out on. I have had the privilege of mentoring many of these individuals. I think it is tragic they are not given that opportunity.
The question of creating these spots, obviously, is very much dependent on capacity. I respect the fact that Canada’s health care system, while federally funded, is provincially run. We have had many successful opportunities in certain provinces where we have created residency spots for Canadians studying abroad.
The Practice-Ready Assessment program, on the other hand, is directed at individuals who have come to this country as fully trained physicians who are now in the process of attaining their Canadian credentials. Again, because of capacity issues, these individuals go through very stringent screening, examination and language testing processes, but then they wait for an opportunity to enter the system.
We feel that this Practice-Ready Assessment that can run anywhere between 12 and 16 weeks, mentored and carefully monitored by Canadian-trained physicians in academic and community environments, would afford us an opportunity to get them up to the acceptable standards of our colleges and to enter practice. Thank you.
Senator Ravalia, first, I want to thank you and your colleagues for having done this report and for providing a pathway. I also want to thank you for the prescriptions.
In the last few years, I have observed young people from my region receiving their degree and coming back to practise in the region. However, they don’t want to be family doctors. They don’t want to open up an office and have a secretary given the expenses of all that.
I would say 95% of them end up attending to the emergency room. Now we don’t have one emergency room; we have two emergency rooms because of the lack of family doctors. We seem to be in this situation with new doctors who don’t want to open up a family practice. What would the solution be to that? Is it a problem caused by the provincial administration or the local health authority?
Instead of working in the emergency room, if the new doctors in my area opened up a family practice or clinic, people would be better served than waiting 12 to 16 hours at emergency. What would the solution be to that?
Thank you very much, Senator Ringuette. That is a question that those of us who have been involved in administration or academic medicine wrestle with.
Historically, the percentage of physicians who are interested in going into primary care or family medicine has varied between 25% and 40%. Part of the reason is that a lot of our medical training is actually done in tertiary care environments, in large hospitals and academic centres, where the value of a family physician is generally underrated. They are attracted to cardiology, neurology, neurosurgery and vascular surgery. That’s one element.
We need to shift more of our training for family doctors into rural communities, where they are able to shadow and spend lengthy periods of time in a primary care environment that is functional, versatile and attractive.
Second, there is a significant pay differential between primary care and specialties. In some instances, a family doctor may make less than a half or even a third of what an ophthalmologist might make, and they are trying to run a business.
There are multiple prongs that need to be addressed: First, how do we make this more attractive; and second, how do we ensure that family physicians are remunerated in a way they should be entitled to given their training and service?
The time for debate is up. Are you asking for more time to answer the question?
If my colleagues would agree.
Only if you answer the question.
Thank you, Senator Plett.
The most crucial issue — and this has happened in other jurisdictions — is the way that the business of medicine should be taken out of the hands of the physician and provided more in government-based buildings where you have full primary care access: physicians working hand in hand with nurse practitioners, social workers, pharmacists and other health professionals. Thank you.
Honourable senators, I am also rising to address the Speech from the Throne, following on from my colleagues Senator Omidvar and Senator Ravalia.
We are focusing on the physician shortage issue, not every single problem in our health care system, though those need to be addressed as well.
My remarks will focus on an opportunity to build on what already exists and is already in place to create a national program that would rapidly and cost-effectively ensure a pathway to medical licensure for internationally trained physicians. These are physicians who have graduated from medical school, done their postgraduate training, practised in a different country — some for many years — come to Canada and who are Canadian citizens or permanent residents. That’s the group.
This kind of program was an extremely modest investment to provide a route through which thousands of physicians, who are in critically short supply, could enter practice every single year. Imagine what this would mean for all those who do not have a family physician or are waiting for months or even years to see a specialist in those areas in which specialists are in short supply.
This route to physician licensure is through the Practice-Ready Assessment, or PRA, as Senator Osler mentioned. It allows internationally trained physicians, or ITPs, to demonstrate their clinical readiness in a supervised setting, often in a community in which they will then work when they finish.
Let me be clear: This route to practise already exists in some provinces, but it is not nationally organized and there has been little or no coordinated attempt to build on this to create a national program ensuring that the PRA can be effectively used to address the physician numbers crisis we have been facing for at least a decade.
Colleagues, for decades, there has existed a cost-effective solution for assessing the clinical competencies of experienced physicians: the PRA. But during the last decade, only about 1,000 qualified physicians have been able to navigate a PRA.
However, according to Dr. Gus Grant, a registrar of the College of Physicians & Surgeons of Nova Scotia, there are currently about — are you ready for this — 13,000 qualified physicians waiting for a chance to get into a PRA. You can do the math. We currently stand at a shortage of 6,000 to 7,000 primary care physicians in Canada, yet we have been sitting on a solution that could have mitigated this crisis many years ago.
Had a national PRA program been in place, it is very possible that we would not be in this situation now. Let me be very clear about the PRA route to licensure: It is tailored specifically for those experienced, mid-career physicians who have already been practising medicine in another country. It is not — as Senator Ravalia has pointed out — for recent medical school graduates who have not previously practised medicine. These are physicians who are already experienced.
In addition, these internationally trained physicians have passed all of their Canadian examinations to ensure they meet the same standard as a Canadian physician. Many of these ITPs may be members of linguistic or cultural communities in Canada that are struggling to find physicians and know their language and culture.
These physicians have often immigrated to Canada with the understanding that they could use their medical skills when they got here, but guess what? They can’t. So, while their communities are under-serviced, they cannot access a simple program that would meet the needs of the communities in which they may reside.
Colleagues, this is blatantly unfair for everyone.
These are the doctors who are driving taxi cabs while over 6 million Canadians don’t have a family physician, and colleagues, they have been here all along.
So what is a PRA? What goes into a PRA? It is a route to licensure that ensures that experienced ITPs who have trained and practised outside Canada have the necessary competencies for safe and effective medical practice in Canada. It is an in‑depth evaluation of the ITP’s competencies conducted under direct supervision by a trained physician assessor in a clinical setting, usually over a period of three months.
But prior to entering the PRA, the applicant must have their medical school and residency training credentials tested, pass a suite of examinations, demonstrate language proficiency and meet other exhaustive requirements. At the time of their entry into the program, the physician has already demonstrated that they meet the necessary standards for Canadian medical practice. It is the PRA that is the icing on the cake.
So it is an intensive three-month evaluation of their clinical work under the supervision of an experienced physician. Upon completion of this assessment, they meet the same standards for licensure that any Canadian medical graduate must meet for licensure.
Since the assessment period is only three months long, ramping up capacity in PRA availability will rapidly help us address the huge shortfall of available physicians. As well, graduates from PRA often sign return of service agreements that direct their practice to parts of Canada where the need is greatest, particularly rural practice. Simply put, colleagues, the PRA is one of the most cost-effective ways to quickly increase the pool of highly trained physicians who can meet the care needs of Canada, and it can meet it now.
There actually is, colleagues, a framework for a national PRA assessment network. It was recently created by the Medical Council of Canada. Indeed, with proper funding, the Medical Council of Canada could become a home for the national PRA program.
Currently, somebody who wants to access a PRA must go from province to province, bouncing like a Ping-Pong ball across a table, and even if they have clearly met all the qualifications, they often can’t get in because there are no available slots.
My home province of Nova Scotia is finally instituting a robust, centralized and coordinated PRA program under the leadership of the College of Physicians & Surgeons of Nova Scotia and in collaboration with the Medical Council of Canada. Nationally, it is the first of its kind.
Previous iterations of the program were run off the side of the desk by highly committed physicians at Dalhousie University, but they were not provided with the funding or other supports needed to scale up the program. So this is a necessary first step, but it is a drop in the bucket.
However, simply by investing in the creation of a national PRA program and providing funding for these slots, the federal government could turn this drop in the bucket into a river of opportunity.
Colleagues, what about the cost? Right now, the cost of putting one experienced physician through a PRA program assessment — are you ready for it — is about $35,000. That’s it. If a national program created 500 PRA slots across Canada, it could probably graduate about 1,500 physicians a year at $35,000 per physician. Do the math and tell me if that’s not a good return on investment.
Furthermore, a national PRA program could be periodically reviewed and tweaked to better reflect physician human resource needs. Its outputs could actually be managed. That would be unique. It could even help inform the criteria for potential physician immigrants to Canada.
Colleagues, establishing a national PRA program and funding the sites could be done by the federal government directly. Provinces and territories would continue to set licensing standards and the appropriate administrative structures would oversee the PRA sites. This requires federal leadership and direct federal investment. There is no question that this could be done. Colleagues, it must be done. Thank you.
Senator Kutcher, will you take a question?
Absolutely.
Can you tell us how the situation is handled in other countries, like the U.S., Australia and New Zealand? Do they have a better program for addressing physicians who might want to practise there?
Thank you very much for that question. I hesitate to speak specifically about some of those countries because I don’t know all the aspects of their pathways to licensure, and I do not want to misspeak about that. Suffice it to say, there are more pathways to licensure and more ability to absorb people into the system in some of those countries than there are in Canada. For example, it is a shame that physicians who have trained abroad and who are Canadian citizens do not come to Canada but go to our neighbour to the south. What a loss of human resources; what a travesty. That is just not good enough. That was what Senator Ravalia was talking about with regard to increasing the residency training programs.
The other part is the Practice-Ready Assessment, or PRA, programs that I am focusing on. We have physicians who have immigrated to Canada and were practising in their home country.
Let me tell you a story about a neurosurgeon who was the head of a department in another country; I won’t name the country now. He was an outstanding clinician, an outstanding teacher and a wonderful educator. He can’t get in. What an incredible loss to us. That’s one little story. I could tell you hundreds of those stories. That is not the way to handle access to health care.
Thank you, Senators Kutcher, Ravalia and Omidvar, for talking about this topic. I’m not sure I understand whether the national framework is already in place in Nova Scotia. However, the provincial colleges of physicians are very protective of their turf, as you know. That’s a big part of the impediment. They keep passing the buck. The college says yes, but the university says no, because they have to spend money on these people. How do you think this national framework can be implemented?
Thank you very much, Senator Mégie, for that question. Shamefully, as Pogo said, We Have Met the Enemy and He Is Us. I want to be very clear: My colleagues who will look at this later, coast to coast to coast, will be annoyed, but the reality is that our medical schools and our physician guilds have not done the kind of job that we should have done to ensure that this works.
Second, the provincial governments have also failed. This is not news, colleagues. When the Barer–Stoddart report came out in the early 1980s, I happened to be the Vice-President of the Canadian Association of Internes and Residents and President of the Professional Association of Residents of Ontario. We wrote our counter-report, and at that time, in the early 1980s, we predicted a huge physician shortage in Canada; it wasn’t news to anybody. It wasn’t news to any province or any territory that this was going to happen.
What we have seen for decades here is a kicking of the ball down the road to the next group and a failure to address this. We can actually do this, Senator Mégie. We can create a national program, and if the province wants to license these people, they can license them. I would like to see a province standing there with 3,000 physicians saying, “We’re ready; we have done the program.” If the province says, “No, we’re not going to license you,” how will the voters react?
