Study of Registration Practices of the
COLLEGE OF PHYSICIANS AND SURGEONS OF ONTARIO, 2007

1. INTRODUCTION
2. BACKGROUND OF THE REGULATORY BODY
3. REGISTRATION PRACTICES
4. BRIDGING PROGRAMS
1. a. Bridging Programs
2. b. Additional (Non-bridging) Programs for IMGs
5. MUTUAL RECOGNITION AGREEMENTS
6. APPLICANTS’ INTERACTIONS WITH REGULATORY BODY
7. CHANGES SINCE THE 2005 SURVEY
8. REGISTRATION INFORMATION AND STATISTICS
9. SOURCES

ISBN 978-1-4249-6472-7 [HTML English version]

1. INTRODUCTION

The Office of the Fairness Commissioner (OFC) undertook a study of registration practices of Ontario's regulated professions during the fall and winter of 2007–2008. The purpose of the study was to understand each regulated profession's 2007 registration practices and to establish baseline data and information to enable the OFC to measure progress as it fulfills its mandate under the Fair Access to Regulated Professions Act, 2006.

This report reflects the registration practices of the College of Physicians and Surgeons of Ontario as of December 31, 2007. Information in this report was gathered from:

face-to-face meetings with registration staff of the regulatory body
additional documentation provided by the regulatory body
relevant websites
career maps for the profession posted on the Ministry of Citizenship and Immigration's website (where applicable).

The College of Physicians and Surgeons of Ontario also provided registration information and statistics for 2005, 2006 and 2007 through a standard spreadsheet designed by the OFC.

An analysis and summary of the findings for all of the regulated professions is contained in the OFC's Ontario’s Regulated Professions: Report on the 2007 Study of Registration Practices.

2. BACKGROUND OF THE REGULATORY BODY

a. Legislation

The College of Physicians and Surgeons of Ontario (CPSO) operates in accordance with the Regulated Health Professions Act (RHPA),1991 and the Medicine Act.

b. Protected Titles

According to the Medicine Act, no person other than a member of the CPSO shall use the title “osteopath,” “physician” or “surgeon,” or any variation, abbreviation or equivalent in another language of these titles. This restriction does not apply to the use of the title “surgeon” by a member of the Royal College of Dental Surgeons of Ontario.

According to the RHPA, no person other than a member of the CPSO shall use the title “doctor,” or any variation, abbreviation or equivalent in another language of this title, in providing or offering to provide health care. This restriction does not apply to the use of the title “doctor” by a member of the College of Chiropractors of Ontario, the College of Optometrists of Ontario, the College of Psychologists of Ontario or the Royal College of Dental Surgeons of Ontario.

According to the Health Systems Improvement Act, 2007 (Bill 171), a member of the College of Naturopaths of Ontario will be permitted in future, on a date to be specified by the Lieutenant Governor in Council, to use the title “doctor” in writing if the phrase “naturopathic doctor” immediately follows his or her name.

c. Definition of the Profession

The CPSO regulates the practice of medicine to protect and serve the public interest. It issues certificates of registration to doctors to allow them to practise medicine, monitors and maintains standards of practice through peer assessment and remediation, investigates complaints against doctors on behalf of the public and disciplines doctors who may have committed an act of professional misconduct or incompetence.

d. Labour Market

Ontario has a serious shortage of family doctors as well as of specialists in certain areas. Although the CPSO is interested in labour market trends and being a partner in system solutions, it is not within its mandate to respond to supply and demand issues.

Additional information regarding labour market trends can be gathered from the Canadian Institute for Health Information and the Ontario Physicians Human Resource Data Centre.

e. New Developments Within the Profession

The CPSO is a policy-oriented body that is involved in many different areas such as the supply of and demand for professionals, levels of care, patient selection by physicians and physician behaviour.

The CPSO sees the issue of patient selection as an area where it could be more involved. Selection must not be discriminatory or violate the Human Rights Code. The CPSO is developing a policy on patient selection and is involved in developing national solutions with other organizations to enhance patient care.

The Physician Resources Task Force, established in 2001, is composed of representatives from the Ministry of Health and Long-Term Care, the Council of Ontario Faculties of Medicine, the Ontario Medical Association and the CPSO. This task force was created to work on issues such as additional training spots, selection criteria to access graduate or postgraduate training spots, proposals on an independent health human resources planning body, an interprofessional care and physician assistants initiative, and initiatives to create a national body (Physicians Credentials Registry of Canada) to evaluate credentials for international medical graduates. The CPSO is registered to use the credentials registry, but it may take several years to implement it. There are pilots of this project in Nova Scotia and British Columbia.

The CPSO Council passed a regulation amendment “in principle only” to restrict the use of specialist titles, restrict the use of the term “surgeon,” specify requirements for advertising or promotional materials and make additions to the professional misconduct regulations. The title “surgeon” will be able to be used only by those certified in a surgical specialty by the Royal College of Physicians and Surgeons of Canada (RCPSC) or under the CPSO’s “Recognition of Non-family Medicine Specialists” policy. For example, a limited number of physicians from other jurisdictions who have the requisite training and have been assessed by RCPSC specialists and found to be practising at the same standard would be allowed to use this title.

If approved, the changes would address public confusion and lack of clarity about physicians’ certification and training. These amendments involve Ontario Regulation 114/94, Part II: Advertising, and Ontario Regulation 856/93, Professional Misconduct. These amendments are not yet in effect. Further analysis will be conducted and reported to inform discussion at the CPSO Council’s meeting in April 2008.

The Health System Improvements Act, 2007 (Bill 171) affected the CPSO in the following areas:

The Medicine Act was amended to raise the penalty amounts for the misuse of the titles “osteopath,” “physician” and “surgeon” by non-members of the CPSO.
The Medicine Act was amended to raise the penalty amounts for any non-CPSO member who holds himself or herself out as a person who is qualified to practise in Ontario as an osteopath, physician or surgeon or in a specialty of medicine.
Psychotherapy is now listed as an authorized practice under the Medicine Act. The Psychotherapy Act, 2006 regulates the new profession of psychotherapy and creates the College of Psychotherapists of Ontario (CPO). No person other than a member of the CPO shall use the title “psychotherapist”. At the same time, the section allows certain members of regulatory colleges other than the CPO to perform the controlled act of treating by means of psychotherapy. These include doctors (medical), nurses, psychologists and occupational therapists (the latter only in accordance with regulations). Although these regulated health professions are allowed to practise psychotherapy, only members of the CPO are allowed to use the title “psychotherapist.”

f. Staffing

The CPSO staff consists of 263 employees. The majority of staff are full-time. Approximately 24 employees are assigned to the registration process on a full-time basis.

3. REGISTRATION PRACTICES

a. Registration Requirements and Application Process

The CPSO defines an applicant as somebody who completes and submits an application form and pays the fee.

i. Basic Requirements for Registration

The qualifications and requirements for registration with the CPSO are outlined in the registration regulation of the Medicine Act.

Domestic Graduates

Medical graduates generally go through two stages of registration to practise medicine in this province:

First, they obtain a certificate of registration authorizing postgraduate education.
Second, once they complete the required postgraduate training and Canadian examinations, they obtain a certificate of registration authorizing independent practice.

Certificate of registration authorizing postgraduate education: A postgraduate education certificate is required to engage in postgraduate medical training at an Ontario medical school. It may be renewed annually. It is obtained after graduation from an accredited medical school in North America or an acceptable medical school outside of North America and it requires, as a precondition to issuance, a confirmed postgraduate education appointment at an Ontario medical school. There are terms, conditions and limitations attached to the certificate. The holder may practise medicine only as required by the postgraduate program and only in clinical teaching units or settings affiliated with a postgraduate program. The holder may not charge fees for services.

Certificate of registration authorizing independent practice: An independent practice certificate authorizes the holder to engage in independent, unsupervised medical practice anywhere in Ontario, subject to the limitation that the holder of the certificate can practise only in the areas in which he or she is educated and experienced.

International Medical Graduates

To practise medicine in Ontario, whether as family practitioners or specialists, international medical graduates (IMGs) must have all the Canadian postgraduate qualifications required for an independent practice certificate from the CPSO.

IMGs are subject to the same limitation as noted above for domestic graduates: that the holder of the certificate can practise only in the areas in which he or she is educated and experienced.

However, in keeping with the CPSO's commitment to proactively seek ways to reduce barriers to registration for qualified candidates, the CPSO Council has approved a number of policies relevant to IMGs.

ii. Requirements for an Independent Practice Certificate

The requirements to obtain an independent practice certificate are as follows:

A medical degree from an accredited Canadian or US medical school or from an acceptable medical school listed in the World Directory of Medical Schools
A pass standing on Parts 1 and 2 of the Medical Council of Canada Qualifying Examination (MCCQE)
Certification by examination by either the Royal College of Physicians and Surgeons of Canada (RCPSC) or the College of Family Physicians of Canada (CFPC)
- To become eligible for RCPSC certification exams, applicants must first complete a residency program, usually in Canada.
- To become eligible for CFPC certification exams, applicants can take one of two routes: residency-eligibility, which requires completion of 24 months of family medicine residency training in accredited programs in Canada or the United States; or practice-eligibility, which requires completion of five years of practice experience (the two most recent must be in Canada) and current possession of a licence to practise in a province or territory in Canada.
Completion in Canada of one year of postgraduate training or active medical practice, or completion of a full clinical clerkship at an accredited Canadian medical school
Canadian citizenship or permanent resident status or a work visa.

Once the independent practice certificate (or any class of certificate) is issued, applicants become members of the CPSO and the profession.

b. Documentation Required from Internationally Trained Individuals

i. Standard Documentation

An internationally trained individual requires two different types of documents.

General Documents

These are required of every applicant regardless of the certificate:

copy of the medical degree, sent directly from the medical school to the CPSO
application form
copy of passport
proof of immigration status/work permit
credential documents including certificates of standing covering past practice in other jurisdictions.

Specific Documents

These documents vary depending on the class of certificate the applicant is seeking, but generally all such documents must come directly to the CPSO from the source organization. For example, the certificate from the College of Family Physicians of Canada as well as the certificate from the Royal College of Physicians and Surgeons of Canada should go from the sources directly to the CPSO.

ii. Options for Applicants with Unavailable/Destroyed Documents

Under the policy approved by the CPSO’s Registration Committee, applicants with unavailable/destroyed documents would talk directly to the CPSO and present available documentation, if any. The CPSO would also consider a letter from a former professor or other official certifying a candidate’s qualifications. Such letters must be sent directly to the CPSO. Applicants may also provide their own notarized declaration describing their situation.

In addition, the CPSO has a database with documents from different medical schools around the world. The CPSO can compare the documents provided by the applicant with the documents from the database. If the documents are not in English, the applicant must have them translated by a certified translator.

c. Credential Assessment (Third Party and/or Internal)

The CPSO conducts credential assessments in-house. Its credential assessment group consists of seven people — non-members of the profession — under the direction of the supervisor of the credential section. They are trained to carry out assessments by peers, supervisors, managers and senior staff according to CPSO policies. Approximately one year of training is needed before a new staff member can conduct assessments independently.

The CPSO does the credential assessment for IMGs applying to the CPSO for registration. As long as the medical school degree obtained overseas was based on completion of a curriculum similar to a Canadian medical school and is listed by the World Health Organization, it is deemed an acceptable degree in medicine for CPSO registration.

The Centre for the Evaluation of Health Professionals Educated Abroad (CEHPEA) also performs assessments for IMGs. This assessment is used by IMGs to support their applications for residency positions through the Canadian Resident Matching Service (CaRMS). The CPSO does not use the CEHPEA assessment for registration purposes.

d. Academic/Program Requirements

To be registered with the CPSO, an applicant must have attained a medical degree from an accredited Canadian or US medical school, or from an acceptable medical school that is listed in the World Directory of Medical Schools published by the World Health Organization and that has a curriculum substantially similar in content and duration to an accredited Canadian or US school.

e. Work Experience Requirements

To be registered with the CPSO under the independent practice class, an applicant must complete one year of postgraduate training or active medical practice in Canada, or a full clinical clerkship at an accredited Canadian medical school. This practical experience can be earned anywhere in Canada.

The Registration Committee has the authority to grant exemptions to the work experience requirement. For instance, this could happen if an applicant was trained in the United Kingdom, and his or her training was also approved by the RCPSC.

f. Examinations

The CPSO does not administer any examinations. Examinations are administered by three national examination bodies. In addition, three programs of assessment and preparation are available to assist IMGs with entry to the profession.

Exemptions from exams may be granted under certain circumstances. The Registration Committee has the authority to grant individual exemptions for certain cases supported by strong reasons. In addition, Council has passed a policy that allows the CPSO to issue restricted certificates of registration, in certain circumstances, to individuals who have not successfully completed all of the examination requirements.

The CPSO does not provide any assistance or preparatory materials to applicants taking examinations. Exam preparation is part of the residency training. The Medical Council of Canada has some resources to assist applicants, such as sample questions and a self-test for the evaluation of IMGs.

i. Medical Council of Canada

The Medical Council of Canada (MCC) administers Parts 1 and 2 of the Medical Council of Canada Qualifying Examination (MCCQE). These exams are national and standardized exams; in other words, all applicants across the country take the same exams.

MCCQE Parts 1 and 2 must be taken by IMGs as well as by Ontario and Canadian graduates. Parts 1 and 2 are offered twice a year in various centres across Canada. There is no limit on how many times a candidate may attempt to pass the exam.

To be eligible for MCCQE Part 1, IMGs must pass the Medical Council of Canada Evaluating Examination (MCCEE). The MCCEE is held in various locations throughout Canada and the world, and is open to all IMGs holding an acceptable medical degree. The MCCEE is the starting point for IMGs.

The World Health Organization (WHO) and the International Medical Education Directory (IMED) publish a list of international medical schools annually. Graduates holding a diploma from a medical school accredited by the Committee on Accreditation of Canadian Medical Schools or the Liaison Committee on Medical Education of the USA are not required to take the MCCEE.

For access to MCCQE Part 2, both a pass standing on Part 1 and previous completion of 12 months of postgraduate training are required. This training may be taken anywhere in the world.

MCCQE Part 2 assesses the competence of candidates: specifically the knowledge, skills and attitudes essential for medical licensure in Canada, following a minimum of 12 months supervised postgraduate clinical medical training or postgraduate osteopathic clinical training and prior to entry into independent clinical practice.

MCCQE Part 2 includes sections on medicine, pediatrics, obstetrics and gynecology, preventive medicine and community health, psychiatry and surgery, as well as in allied disciplines considered essential for competence in general medical and health care as defined by the objectives developed by the MCC.

ii. Royal College of Physicians and Surgeons of Canada

The Royal College of Physicians and Surgeons of Canada (RCPSC) is the national examining and certifying body for medical specialists in Canada. The RCPSC also accredits Canadian specialty training programs. RCPSC examinations are offered once a year around May or June, and each applicant is entitled to three attempts.

Access to RCPSC examinations is gained through completion of an RCPSC-accredited residency program in Canada or an RCPSC-recognized residency program in the United States.

Limited access is available through completion of certain international specialty training programs that have been previously assessed and approved by the RCPSC. Exams are held at various locations within Canada depending on the specialty.

To respond to societal needs and to address the shortage of specialist physicians in Canada, the RCPSC has developed a variety of routes to certification so that qualified specialist physicians, including IMGs, can attain full RCPSC certification:

Traditional (i.e., RCPSC training plus examination).
Academic certification (in Canada and outside Canada): The academic route to RCPSC certification helps Canadian faculties of medicine recruit and retain internationally trained specialists as full-time clinical faculty.
Jurisdiction-approved training (for IMGs): The RCPSC has assessed 29 international jurisdictions and deemed them as having met RCPSC criteria. The RCPSC will assess the individual training of graduates of these particular jurisdictions to determine the extent to which they have successfully met and completed the RCPSC training requirements.
Practice Ready Assessment (for IMGs): The PRA process (see section 3.f.v below) is intended for IMGs in Canada with certification from an international jurisdiction.
Individual competency assessment for IMGs: The RCPSC Credentials Committee has developed a set of criteria for the assessment of IMGs' individual training.
Practice Eligibility Route (for subspecialists): The RCPSC Council recently approved a policy outlining the criteria and process for certification via the Practice Eligibility Route (PER). Implementation of the policy will begin with Fellows certified in a primary discipline who began practising in an Accreditation Without Certification (AWC) subspecialty prior to the existence of RCPSC-accredited training in their chosen subspecialty. Two additional groups of physicians will also have access to certification examinations via the PER: physicians practising in a new RCPSC subspecialty (recognized within the last five years) and physicians practising in disciplines that have not yet been recognized as RCPSC subspecialties. The PER is not open to physicians who have had RCPSC-accredited training.

iii. College of Family Physicians of Canada

The College of Family Physicians of Canada (CFPC) is the national examining and certifying body for family medicine practitioners in Canada. In order to practise family medicine in Ontario, individuals must be certified by the CFPC. The CFPC also accredits family medicine training programs in Canada. Currently, the CFPC recognizes or approves postgraduate residency training in family medicine only from Canadian and US training programs. The CFPC has been unable to assess training programs in other countries.

CFPC examinations are offered twice a year, at the end of April and the end of October, and each applicant is entitled to three attempts to pass the exam. Applicants who fail three times can remain as CPSO members but additional training and/or supervision may be required. After regaining CFPC eligibility, applicants are entitled to three additional attempts.

Access to CFPC examinations is gained through two routes: “residency-eligibility” or “practice-eligibility.”

Residency-eligibility requires completion of 24 months of family medicine residency training in accredited programs in Canada or the United States.
Practice-eligibility requires completion of five years of practice experience (of which the two most recent must be in Canada) and current possession of a licence to practise in a province or territory in Canada.

Family physicians, also called general practitioners, from other jurisdictions throughout the world who want to practise medicine in Ontario must apply to the Canadian Resident Matching Service (CaRMS) to access and compete for Postgraduate Year 1 (PGY1) family medicine residency positions. In order to be eligible to apply to CaRMS, individuals must be Canadian citizens or permanent residents; pass the Medical Council of Canada Evaluating Exam (MCCEE); and demonstrate language proficiency.

Individuals applying to CaRMS may want to be assessed at the PGY1 level first by taking the General Comprehensive Clinical Examination 1 (CE1) offered through the Centre for the Evaluation of Health Professionals Educated Abroad (CEHPEA). The CE1 is a general broad-based comprehensive clinical examination designed to test a candidate’s appropriateness for the PGY1 level. It is often referred to as a Clinical OSCE (Objective Structured Clinical Examination). All eligible candidates applying for assessment to family medicine or to a specialty at the PGY1 level will take the CE1.

It is not mandatory to be assessed by CEHPEA; however, many programs state that preference may be given to those IMGs who are assessed. When applying to CEHPEA, applicants are required to pass both the MCCEE and MCCQE Part 1 exams.

iv. Centre for the Evaluation of Health Professionals Educated Abroad

The Centre for the Evaluation of Health Professionals Educated Abroad (CEHPEA) offers two assessment streams:

Family Medicine Stream (general or PGY1 level assessment)
Specialist Stream

The CEHPEA is an entry point through which IMGs in Ontario may gain access to the RCPSC or CFPC qualifications required for independent practice. It serves as an orientation and assessment centre for access to the selection process for the residency positions available for IMGs in Ontario. Obtaining a residency training position is a highly competitive process.

The CEHPEA assesses IMGs to determine their readiness to enter residency training. Candidates who have successfully completed the CEHPEA assessment may be selected for a residency program at one of the six Ontario medical schools. Another way to obtain an Ontario residency position is to apply to the Canadian Resident Matching Service (CaRMS). IMGs seeking entry to an Ontario residency position at the PGY1 level may apply directly to the CaRMS, but preference is given to those who have completed the CEHPEA assessment.

The CEHPEA provides assessments for IMGs for direct entry training in family medicine or many of the direct entry specialties. (A limited number of specialties are currently being assessed. The assessments offered for 2007/2008 are in anaesthesia, dermatology, anatomical and general pathology, general surgery, internal medicine, ophthalmology, orthopaedic surgery, otolaryngology, pediatrics and psychiatry.) Candidates must select one specialty for assessment.

The CEHPEA also offers written and clinical assessments for candidates applying for PGY2 or Practice Ready Assessment (PRA) training and the Pre-Residency Program for Family Medicine for candidates who have been successfully matched with a family medicine residency-training program in Ontario.

These requirements are mandatory for all assessments:

All applicants must demonstrate language proficiency (English/French).
All applicants must pass the MCCEE and MCCQE Part 1.
For PGY2 (Postgraduate Year 2) assessment, applicants must have:
- Undertaken training as a second-year postgraduate medical resident
- Completed an assessment at the second-year residency level
- Completed at least one year of postgraduate medical education (as intern, resident, or house officer).
For PGY1 (Postgraduate Year 1) assessment, applicants must have:
- Undertaken training as a first-year postgraduate medical resident
- Successfully completed an undergraduate medical program.

v. Practice Ready Assessment

The CEHPEA also offers the Practice Ready Assessment (PRA). This program enables qualified and experienced IMG specialists to start specialty practice in Ontario without being required to complete a full Canadian residency program. Selected IMG specialists undergo a six-month assessment, which, if successfully completed, is followed by a five-year period of monitored specialty practice in an underserviced Ontario community. During this five-year period, the IMG is expected to pass the MCCQE Parts 1 and 2 and the examinations of the RCPSC or the CFPC. The PRA is limited to a varying number of specialties, as determined by provincial need.

The six-month assessment is conducted in a supervised clinical setting at a medical school in Ontario. Upon completion, there are three possible outcomes:

Applicants are deemed practice ready and may proceed to apply for registration with the CPSO and certification from either the CFPC or the RCPSC.
Applicants are found lacking in a particular area but are deemed trainable. A postgraduate educational experience is prescribed in order to remediate the professional deficiency. The applicant undertakes the prescribed education as a postgraduate medical resident for a maximum of two years.
Applicants are found significantly lacking in a number of areas, such that two years of postgraduate education would not be sufficient to remediate the deficiencies. These applicants are dismissed from the program.

Once applicants are deemed eligible by the CEHPEA at the PGY2 and/or PRA level, applicants will participate in a Specialty Specific Written Examination (SWE). The SWE is a series of examinations designed to test a candidate's appropriateness for the PGY2 or Practice Ready Assessment levels in the specialty stream. Program directors will then decide, based on many criteria, whether to extend an invitation for an IMG to attend the Clinical Exam 2 and possibly an interview. Program directors will offer successful candidates PGY2 residency training positions or a six-month supervised clinical assessment (PRA) position.

vi. Pre-Residency Program

Participation in the Pre-Residency Program (PRP) is mandatory for all applicants accepted into a family medicine residency-training program in Ontario. The four-month-long program will assist IMG candidates to acquire the necessary competencies to prepare them for participation in family medicine residency training. The PRP is an intensive preparatory program that addresses key competency areas. The PRP is not deemed to fulfill any of the residency requirements of the program.

g. Language Requirements

The CPSO requires that every applicant be able to communicate effectively in English or French; however, it does not test for language skills. The CPSO assumes the language proficiency of applicants if they succeed in passing all parts of the registration process.

h. Fees^[1]

Annual membership fee to May 31, 2008	$1,050
Annual membership fee from June 1, 2008 to May 31, 2009	$1,200
Penalty for payment of annual fee received after June 1	$200
Annual membership fee for Postgraduate Education class	$140
Application fee (excluding Postgraduate Education class) ^[2]	$515
Application fee under subsection 3(6) of O. Reg. 865/93	$715
Application fee for Postgraduate Education class	$115
Application fee for Supervised Short Duration class ^[3]	$215
Certificate of Professional Conduct	$50
Certificate of Status of Registration	$50
Membership diploma^[4]	$75
Change of name in CPSO register	$25
Replacement membership certificate	$10
Replacement Certificate of Registration	$10
Duplicate receipt for fee payment	$10
Fee for use of college seal	$ 40
Certificate of Authorization application fee (for members incorporating their practice)	$365
Certificate of Authorization annual renewal fee	$130

Additional Fees

Fees for MCCEE:
- Credentialing fee (non-refundable): $200
- Examination fee: $850

Fee for MCCQE Part 1: $680
Fee for MCCQE Part 2: $1,500
Fees for CFPC exams:
- Fee for Examination of Special Competence in Emergency Medicine 2008: $2,160
- Fee for Certification Examination in Family Medicine, Fall 2007: $1,420
- Fee for Certification Examination in Family Medicine, Spring 2008: $1,590

Fees for RCPSC exams: (Spring 2008)
- Fee for Principles of Surgery Examination: $510
- Fee for Comprehensive Objective Examination (all Specialties): $2,810

CEHPEA Fees:
- Application fee: $150 (non-refundable)
- Fee for Clinical Skills Examinations (CE1 and CE2): $500 each
- Fee for Specialty Written Examination (SWE): $275 (for candidates applying for PGY2 / PRA assessment)
- Advanced specialty candidates also applying for PGY1 assessment are required to submit the additional $500 exam fee in order to participate in the Clinical Examination (CE1).

i. Third Parties

Name of Third Party	Relationship to Regulatory Body
Medical Council of Canada	Administers the national exams that assess candidates’ knowledge and skills.
Royal College of Physicians and Surgeons of Canada (RCPSC)	The Royal College of Physicians and Surgeons of Canada is the national examining and certifying body for medical and surgical specialists in Canada.
College of Family Physicians of Canada (CFPC )	The College of Family Physicians of Canada is the national examining and certifying body for family medicine practitioners in Canada.
United States Medical Licensing Examination (USMLE), Comprehensive Osteopathic Licensing Examination (COMLEX), United States Education Commission for Foreign Medical Graduates, US Boards of Medical Specialties	The US organizations/examining bodies do comparable work (accreditation, examination and assessment) to their Canadian counterparts. The CPSO accepts the USMLE and COMLEX examinations taken after 2004 as comparable to the MCC qualifying exams. These exams can be used instead of MCC exams to meet requirements for registration.
Centre for the Evaluation of Health Professionals Educated Abroad (CEHPEA)	The CEHPEA is an entry point through which IMGs in Ontario may gain access to the RCPSC or CFPC qualification required for independent practice. It serves as an orientation and assessment centre for access to the selection process for the residency positions available for IMGs in Ontario.

j. Typical Length of the Process

The length of the CPSO registration process tends to vary depending on whether the applicant is a domestic graduate or an internationally educated professional. For a domestic graduate, the registration process typically takes four to six weeks if the applicant completes the process in orderly fashion and fulfills all the requirements. For an IMG, the registration process can often take four to six months. This difference occurs largely because credentialing of IMGs, unlike that of domestic graduates, involves numerous primary-source verification documents from overseas, which typically take much longer to arrange for and to arrive than primary-source verifications from within Canada.

The time limit for the CPSO application process is one year. Before the file is considered abandoned, the CPSO will contact the applicant to confirm his or her interest in the process. If the CPSO does not hear from the applicant, the file will be closed.

k. Accredited Programs

There are six accredited medical schools in Ontario:

McMaster University, Hamilton
Northern Ontario School of Medicine (a joint initiative of Lakehead University in Thunder Bay and Laurentian University in Sudbury)
Queen’s University, Kingston
University of Ottawa
University of Toronto
University of Western Ontario, London.

There are 11 other accredited medical schools across Canada.

Alberta: University of Alberta, Edmonton; University of Calgary
British Columbia: University of British Columbia, Vancouver
Manitoba: University of Manitoba, Winnipeg
Newfoundland: Memorial University of Newfoundland, St. John’s
Nova Scotia: Dalhousie University, Halifax
Quebec: McGill University, Montreal; Université Laval, Quebec City; Université de Montréal; Université de Sherbrooke, Sherbrooke
Saskatchewan: University of Saskatchewan, Saskatoon

l. Internal Review/Appeal Process

For the initial credential assessment stage conducted by CPSO staff, there is no formal appeal process. Instead, applicants assessed as not meeting the registration requirements are referred by the Registrar to the CPSO’s Registration Committee for a decision. Decisions of the Registration Committee may be appealed to the Health Professions Appeal and Review Board (see below).

Communications between credential assessors (or registration inquiries staff) and applicants, especially IMGs applying from abroad, occur very frequently. These communications may be about any aspect of the process but typically focus on credentialing documents received or still pending.

Completed applications undergo a three-level assessment and quality assurance system by CPSO staff prior to issuance of registration. In addition, the computer randomly selects some files for a fourth check. Description of the three-level assessment system is not yet available on the CPSO’s website, but it is expected to be added in the coming year.

For completed applications, the Registrar must make one of two determinations:

To register an applicant
To refer the application to the CPSO’s Registration Committee if the Registrar deems that the applicant has not fulfilled all the registration requirements, if the Registrar proposes to refuse the application or if the Registrar proposes to impose terms, conditions and limitations on the certificate of registration.

The Registration Committee may in turn make an order directing the Registrar to do one or more of the following:

Issue a certificate of registration
Issue a certificate of registration, subject to the applicant completing further training or examinations
Issue a certificate of registration with specified terms, conditions and limitations
Refuse to issue a certificate of registration.

After referral to the Registration Committee, each applicant will have the opportunity to review the documents that the Registration Committee will consider on his or her case. The CPSO ensures that the information the committee receives is relevant material. In addition, applicants can communicate with the CPSO if they want additional information given to the Registration Committee.

The Registration Committee is composed of five physician members and two public members. Of the five physician members, three are Council members and two are non-Council members. Public members are appointed by the Lieutenant Governor in Council.

An applicant who does not agree with the Registration Committee’s decision can appeal the decision at the Health Professions Appeal and Review Board (HPARB). The information about appeals of registration decisions is currently accessible on the CPSO’s website.

The relationship of the review/appeal bodies to the assessment and decision-making bodies in the registration process is an arm’s-length one.

4. BRIDGING PROGRAMS

a. Bridging Programs

i. Communication and Cultural Competence (CCC) Project

This CPSO project is developing a website that illustrates the Considerations of Legal, Ethical and Organization (CLEO) aspects of the practice of medicine, which are a component of the Medical Council of Canada’s evaluating examination. The project is designed to provide Web-based medical literacy and educational tools to address the communication needs of IMGs who wish to apply to one of Ontario’s programs for entry to medical practice.

The CPSO has been very active on the development of this project, which is still in progress.

ii. Career Transitions, Catholic Immigration Centre, Ottawa

This project helps internationally trained physicians identify transferable skills and obtain employment in related health-sector industries. The CPSO does not have any involvement in this program.

iii. Health Sector Pre-Bridging Language Acquisition Project, Mohawk College, Hamilton

This project helps participants prepare to enter health-sector bridging projects by improving their language from Canadian Language Benchmark 5 to Canadian Language Benchmark 7. Four online modules of 50 hours each will help participants develop language skills and improve interpersonal communications by presenting material in a Canadian health care context. The CPSO does not have any involvement in this program.

b. Additional (Non-bridging) Programs for IMGs

i. Registration through Practice Assessment

Registration through Practice Assessment (RPA) is a new pilot project funded by the Ontario Ministry of Health and Long-Term Care to assess internationally trained medical graduates who have extensive practice experience outside of Ontario. This assessment program was developed as part of a larger strategy to find practical solutions to the doctor shortage in Ontario.

Currently, the RPA program is authorized to assess doctors with experience and in active medical practice in a jurisdiction in Canada (excluding Ontario) or the United States. It allows the applicant who is not certified as a specialist by one of Canada's national colleges to gain access to registration through an evaluation of his or her clinical and practice skills, and can be tailored to the individual applicant. This new assessment program focuses on the skills and abilities of an individual doctor in his or her practice rather than looking only at grades and training programs. If a doctor is not currently in active practice, the tools for this type of evaluation are not available — there are no charts to review, no colleagues to interview and no chance to observe doctor-patient encounters to determine if the applicant meets the requisite standards.

ii. Canadian Resident Matching Service

IMGs may apply for entry to an Ontario residency program through the Canadian Resident Matching Service (CaRMS), provided they meet CaRMS eligibility requirements:

Applicants must be either final-year medical students or graduates who have obtained or are obtaining a medical degree by July 1 of the match year.
Applicants must pass the MCCEE or be registered for the September MCCEE and provide CaRMS with the MCC candidate code.
Applicants must be Canadian citizens or permanent residents.
Applicants who were previously registered in a postgraduate medical training program are ineligible.
Preference is given to those who have undergone an assessment by the CEHPEA. When applying to CaRMS, IMGs must decide whether or not to be assessed at the PGY1 level through CEHPEA. It is not mandatory to be assessed; however, most of the program information that is available through CaRMS states that IMGs are highly encouraged or recommended to be assessed.
Demonstration of English- or French-language proficiency through TOEFL or TSE is also required.

The CaRMS program administers the matching process for PGY 1 entry (R-1) residency positions (main residency match); Year 3 family medicine — emergency medicine residency positions; as well as Canadian access to the US electronic application system for postgraduate medical training (ERAS).

All IMGs will be required to sign a return of service agreement with the Ministry of Health and Long-Term Care, in the specialty (including family medicine) in which they have completed residency training.

IMG candidates accepted to family medicine residency programs will be required to complete a Pre-Residency Program, administered by CEHPEA, prior to entering into a family medicine residency program.

All IMG candidates accepted to residency training programs (FM and specialty) will be required to undergo an Assessment Verification Period (AVP). This assessment period is 12 weeks long and is required by CPSO to meet its licensure requirements. If the candidate does not successfully complete the AVP, he or she must leave the residency training program.

The CPSO does not have any involvement in this program.

5. MUTUAL RECOGNITION AGREEMENTS

The CPSO does not have mutual recognition agreements within Canada or other jurisdictions outside Canada. However, the CPSO supports the 1994 Canadian Agreement on Internal Trade (AIT), which encourages labour mobility through such means as provincial portability of professional qualifications. In 2001, the CPSO, along with most other Canadian provincial medical regulatory authorities, entered into a mutual recognition agreement to meet the requirements of chapter 7 of the 1994 Canadian AIT.

6. APPLICANTS’ INTERACTIONS WITH REGULATORY BODY

a. Nature and Frequency of Communication

The CPSO has frequent contact with applicants throughout the process.

b. Backlogs

The CPSO aims to have no backlogs; that is, the CPSO aims to register all eligible applicants in time for their training or practice starting dates in Ontario. The CPSO encourages applicants to apply far enough in advance to afford sufficient time for completion of credentialing and processing of their applications.

The peak registration period at the CPSO is from May to July each year. During this busy period, the CPSO receives approximately 1,500 applications, of which about 60 per cent are postgraduate education applications and 40 per cent are independent practice applications. Additional staff are hired during this period.

c. Complaints Regarding the Registration Process

The CPSO has a registration inquiries unit. This unit is responsible for responding to questions, concerns and problems raised by prospective applicants and also by applicants-in-progress. If the question or problem cannot be answered or resolved at this level, it is referred to the credentials assessor (if applicable) or the supervisor of the inquiries unit. If necessary, an inquiry could go to the credentials supervisor or the department manager.

7. CHANGES SINCE THE 2005 SURVEY

The Ministry of Citizenship and Immigration conducted a survey in 2005 to collect information about occupational regulatory bodies in Ontario.

The CPSO does not have a career map, and there are no plans to develop one. However, the Ministry of Citizenship and Immigration website has links to career maps. The CPSO link leads to the Ministry of Health and Long-Term Care’s IMG site.

The CPSO website is being redesigned to make the information more clear and accessible to the public.

8. REGISTRATION INFORMATION AND STATISTICS

Definitions used in these tables:

Alternative class of licence: a class of licence that enables its holder to practise with limitations; additional registration requirements must be met in order to be fully licensed. Alternative classes of licence granted by the College of Physicians and Surgeons of Ontario are specified under the tables below.

Applicant: a person who has applied to start the process for entry to the profession.

Applicant actively pursuing licensing: an applicant who had some contact with the CPSO within the year specified.

Inactive applicant: an applicant who had no contact with the CPSO within the year specified.

Member: a person who is currently able to use the protected title or professional designation “doctor,” “osteopath,” “physician” or “surgeon.”

Languages in which application information materials were available
Language	2005	2006	2007
English	Yes	Yes	Yes
French¹	No	No	No
Other(s)

¹ The CPSO will converse with applicants in French, but written application materials are in English only.

Countries where internationally educated applicants were initially trained in medicine
Applications received	2005	2006	2007
Largest number	India	India	India
Second-largest number	Saudi Arabia	Saudi Arabia	Saudi Arabia
Third-largest number	United Kingdom	Pakistan	United Kingdom
Fourth-largest number	Egypt	United Kingdom	Pakistan
Fifth-largest number	Pakistan	Egypt	Australia

Staff employed by the CPSO
Number of staff	2005	2006	2007
Involved in registration process	16	17	18
Involved in appeals process	4	6	6

Jurisdiction where members were initially trained in medicine (before they were granted use of the protected title or professional designation in Ontario)
Members	Ontario	Other Canadian Provinces	USA	Other International	TOTAL
Total members	18,079	6,126	335	8,634	33,174
Non-practising members¹	1,611	1,080	33	671	3,395

¹ Retired members and members currently practising outside Ontario.

Applicants processed by the CPSO in 2005
In 2005 (Jan. 1 to Dec. 31)	Ontario	Other Canadian Provinces	USA	Other International	TOTAL
	Jurisdiction where members were initially trained in medicine (before they were granted use of the protected title or professional designation in Ontario)
New applications received¹	1,100	560	53	1,122	2,835
Applicants actively pursuing licensing²	1,115	575	55	1,182	2,927
Inactive applicants³	10	5	3	27	45
Applicants who met all requirements and were authorized to become members but did not become members⁴	0	0	0	0	0
Applicants who became members	1,065	550	50	1,082	2,747
Applicants who were authorized to receive an alternative class of licence⁵ but were not issued a licence⁶	4	1	0	20	25
Applicants who were issued an alternative class of licence⁵	599	288	41	867	1,795

¹Includes all applications received in 2005 plus estimated number of applications received and still in process at year-end.

²Includes all applications carried over from late 2004.

³Includes all applications received in 2005 plus estimated number of applications received and still in process from current and previous year.

⁴The CPSO is not aware of any new registrants who did not enter the profession.

⁵ Postgraduate Education: May practise only as required by the postgraduate training program; certificate expires when the enrolment in postgraduate medical education ceases.

Restricted: Must practise in accordance with specified terms, conditions and limitations on the certificate.

Academic Practice: May practise only in a medical school department while holding an academic appointment; certificate expires when the academic appointment ends.

Short Duration: May practise only to the extent required by the appointment at a public hospital, psychiatric facility or medical school; certificate valid for up to 30 days.

Academic Visitor: May practise only in a medical school department while holding an academic appointment; certificate may be issued for up to 15 months only.

⁶ Includes estimated number of fully completed applications that were withdrawn.

Applicants processed by the CPSO in 2006
In 2006 (Jan. 1 to Dec. 31)	Ontario	Other Canadian Provinces	USA	Other International	TOTAL
	Jurisdiction where members were initially trained in medicine (before they were granted use of the protected title or professional designation in Ontario)
New applications received¹	1,137	548	77	1,287	3,049
Applicants actively pursuing licensing²	1,152	563	79	1,347	3,141
Inactive applicants³	10	7	3	30	50
Applicants who met all requirements and were authorized to become members but did not become members⁴	0	0	0	0	0
Applicants who became members	1,102	538	74	1,247	2,961
Applicants who were authorized to receive an alternative class of licence⁵ but were not issued a licence⁶	5	2	0	25	32
Applicants who were issued an alternative class of licence⁵	632	280	60	1,018	1,990

Applicants processed by the CPSO in 2007
In 2007 (Jan. 1 to Dec. 31)	Ontario	Other Canadian Provinces	USA	Other International	TOTAL
	Jurisdiction where members were initially trained in medicine (before they were granted use of the protected title or professional designation in Ontario)
New applications received¹	1,195	655	78	1,453	3,381
Applicants actively pursuing licensing²	1,220	675	80	1,506	3,481
Inactive applicants³	12	5	3	35	55
Applicants who met all requirements and were authorized to become members but did not become members⁴	0	0	0	0	0
Applicants who became members	1,155	645	76	1,403	3,279
Applicants who were authorized to receive an alternative class of licence⁵ but were not issued a licence⁶	5	3	0	27	35
Applicants who were issued an alternative class of licence⁵	647	356	59	1,128	2,190

9. SOURCES

“About Ontario’s Bridge Training Programs: Medical Graduates.” Ministry of Citizenship and Immigration website: http://www.citizenship.gov.on.ca/english/working/experience/medicalgraduates.shtml. Last accessed: January 15, 2008.

Centre for the Evaluation of Health Professionals Educated Abroad (CEHPEA) website: http://www.cehpea.ca/reqs.html. Last accessed: January 15, 2008.

College of Family Physicians of Canada website: http://www.cfpc.ca/english/cfpc/home/default.asp?s=1. Last accessed: January 15, 2008.

College of Physicians and Surgeons of Ontario website: http://www.cpso.on.ca/. Last accessed: January 15, 2008.

Medical Council of Canada website: http://www.mcc.ca. Last accessed: January 15, 2008.

Royal College of Physicians and Surgeons of Canada website: http://rcpsc.medical.org/. Last accessed: January 15, 2008.

Representatives of the College of Physicians and Surgeons of Ontario met with staff of the Office of the Fairness Commissioner on November 13, 2007, to provide further information for this study.

^[1] The fees are determined by Council and are subject to change according to Council decisions. Increases to all application fees and the annual fee for Postgraduate Education have been proposed and are expected to take effect in April 2008.

^[2] Application fee (non-refundable) for independent practice certificate of registration.

^[3] The Supervised Short Duration Class is for 30 days.

^[4] This is a one-time fee for purchase of a CPSO membership diploma suitable for display in an office.