Hart Failure

Health system in crisis. Medical licensing in Canada is bankrupt

According to the agency that licenses doctors in Newfoundland and Labrador, Memorial University and two Ontario teaching hospitals don’t give medical training good enough for its graduates to practice medicine in Newfoundland and Labrador.

As ridiculous as that sounds, that’s exactly what the College of Physicians and Surgeons of Newfoundland and Labrador told Dr. Paul Hart in a letter from the College’s assistant registrar for licensing, dated 09 September 2022.

The assistant registrar also told Hart that his experience in telemedicine doesn’t count as medical practice, even though the College has had a standard of medical practice on telemedicine for decades and can issue licenses to practice telemedicine under the Medical Act, 2011 and the 2015 regulations that go with it. Virtual care - another name for telemedicine - is one of the cornerstones of the provincial government’s Health Care Accord.

The whole thing is absurd but that’s why Hart cannot get a medical license in Newfoundland and Labrador at a time when the province is desperately short of qualified medical doctors.

In August, Hart completed the screening application and paid the $780 fee the College demands in order to screen potential applicants for a medical licence in the province. Swamped with applications from doctors around the world, medical licensing authorities across Canada use a screening application to spot any obvious missing qualifications that could not be overcome with some added training. It saves everyone time and money.

But in this case it seems to have exposed a serious problem in the College’s administration. Canadian-trained doctors like Hart, who says he also holds the Licentiate of the Medical Council of Canada, normally get straight on to the application process. Hart’s LMCC is one of the key credentials the Colleges in Canada look for. It was established over a century ago by Sir Thomas Roddick, the Newfoundland-born doctor who created a single standard that could apply across Canada for certifying medical skill.

The letter from the College that Hart received *is* poorly written. It looks like a copy and paste collection of paragraphs but it’s clear enough that the assessment of his credentials focused on two areas. It doesn’t say exactly how hart Hailed to meet the standard, just that he did, despite his credentials and the College’s own policies.

One was his post-graduate training. That’s the two years at Sunnybrook and at Sick Children’s Hospital in Toronto that Hart - who is a graduate of Memorial University’s medical school - completed in the mid-1970s before going to Massachusetts. He still holds a Massachusetts medical licence 45 years later. That information is contained on the state licensing board’s profile for Hart, which also shows him as a qualified to practice family medicine, general practice, and urgent care medicine.

The other was the number of patient care hours Hart has had in the last three years. The College requires at least 450 hours or 120 days of patient contact time in total over the past 36 months. Hart’s resume shows he treated patients by virtual care in the United States and worked 60 hours a week several times a year in refugee camps in Greece.

On the face of it, the combination of the two would meet the College’s minimum requirements. But, as CBC reported, the College justified its rejection of Hart with the statement that “virtual [or] telemedicine practice does not qualify toward active practice.”

The letter and the College’s practice standards for doctors don’t agree. They don’t line up. The College’s standard of practice on virtual care (telemedicine) was last updated in May 2021. The standard says that the “College of Physicians and Surgeons of Newfoundland and Labrador recognizes the value of virtual care to improve access to care and increase efficiencies in the delivery of care.”

That’s not surprising given that doctors in Newfoundland and Labrador have used new technology to treat patients remotely for decades. The late Dr. Max House, a former Lieutenant Governor of Newfoundland and Labrador, was a champion of telemedicine and ran a research centre for telemedicine at Memorial University until he died in 2013. What’s astonishing is that the College can have a policy supporting virtual care in one side of the licensing shop and disregard it as care entirely in another.

This could be a one-off, you may be thinking.

Someone had a bad day.

Sure.

That’s an easy way of explaining what clearly doesn’t make any sense. Plenty of people like think there’s more to this simply because the story is absurd on the face of it. The facts don’t line up with our expectations for something as important as figuring out which doctors are fit to treat patients and which aren’t.

It’s a natural reaction to think there must be some simple explanation that makes what the College did right and what everybody thinks is ridiculous was actually the right thing to do. One doctor took to Twitter to explain that these are standards that are applied properly and correctly. The doctor was doing exactly what I just described: she was rationalizing. She was making the facts line up with her assumption that what the College did must make sense.

A few things tell us this wasn’t a simple mistake.

First, the College hasn’t done the obvious thing if it was an easy mistake. No one acknowledged the screw up and had another look at Hart’s credentials.

On the contrary, they doubled down on it. The statement that virtual care doesn’t count as medical practice came *after* CBC contacted them about the letter to Hart. In its emailed statement to CBC - tellingly, no one from the College would do a live interview - the College administration deliberately and publicly repudiated its own standard of practice and long-standing experience in the province using carefully chosen words.

As dumb as that is, that’s what the College did. They deliberately contradicted their own policy.

So, not a mistake.

And while we are at it, that also tells you that the doctor’s rationalisation - this is just the impartial application of standards - is just not true either.

Second, this rejection of a qualified applicant fits with the attitude across Canada among Colleges. None of them recognize medical licences from other parts of Canada. Full stop.

Again. may not be what you are expecting but it is true.

Look at the flow chart right at the start of this column. If someone has a licence in any part of Canada today, they are merely eligible to apply for a licence in Newfoundland and Labrador. There’s no guarantee they will get one.

That’s just another way of saying the College in Newfoundland and Labrador does not recognize that someone with a full licence for unrestricted practice is qualified to practice medicine in Newfoundland and Labrador, today, based on an assessment done by another College that is exactly like the one here. And just to be clear, a person with a full unrestricted licence is Canadian trained or has Canadian credentials like the LMCC. Either that or they have been practicing in Canada so long they have been grandfathered through, as the saying goes.

Just so you are clear what that means, as a doctor licensed in the United States, Hart was eligible to apply for a licence here. If Hart was licensed in Outer Mongolia, he would be eligible to apply for a licence here, too.

The thing is, Newfoundland and Labrador doesn’t recognise *any* doctor with a medical licence anywhere as being qualified to practice in this province until they have paid their fees to the local College, filled out their extensive forms, and submitted to a review by officials at the College of their entire professional education, training, and experience as if they were holding a licence for the first time on the planet.

Doesn’t matter where they are from.

If you think that’s backward, wasteful, and completely unnecessary you are right. Just don’t apply for a job at any of the Colleges. You won’t fit in.

You see, as the top administrator of the College explained to a health forum in 2018 at Memorial University, “it's very important to be clear up front [that] the college's role in relation to health care outcomes and costs is indirect.” She explained what the College did - licence doctors, set standards, and so on - but pointed out that the College did not decide where money got spent in hospitals and what doctors worked where.

Still, it’s a bit odd to think that controlling the number of doctors working in the province was somehow only indirectly related to patient care (outcomes) and the cost of health care overall.

After all, in 2019, it cost the provincial government about $350,000 a year to cover the licence fees and insurance costs for doctors coming into the province from other parts of Canada for temporary fill-in positions called locum tenens, all of whom had to go through the College’s licensing bureaucracy. Some doctors from outside the province have a second licence here for their own reasons. They paid another $150,000 out of their own pockets. On top of that the health department spent another $15 million or so shunting doctors from one part of the province to another, all of which the College had to approve if the doctor went from one health authority to another.

There’s no way to put a dollar value on the weeks and months of paperwork and duplication the College causes in these sorts of applications, which have to be renewed, by the way each time a doctor comes back to the province. It also doesn’t account for the cost for the patient in delayed care or - when a doctor just isn’t available - in getting care at all.

Just to really drive home the turf protection involved here and the costs that go with it, understand that people have been trying since before the First World War to get the Colleges to develop common standards and allow doctors to move easily from one province to another. And in 2012, 100 years exactly after the creation of the Medical Council of Canada and that common licence standard, no doctor can practice in one province based on a full, unrestricted licence in another province.

Not one.

In the late 1990s, the provinces started to lower barriers for trade between provinces and to lower the obstacles to workers moving across the country as well. Among the professions, only the medical regulators stubbornly resisted. Even lawyers - the sort of people you’d expect to argue over every last comma and participle - can work anywhere in Canada based on their licence from one province without having to be re-licensed by the other province. Some 25 years after the start of the interprovincial labour mobility talks, all the Colleges will do is talk about going through the paperwork a bit faster.

All the Colleges exist because the provincial governments in each province decided 150 or more years ago to let doctors regulate themselves in the public interest. For the most part it has worked but over the past 25 years and in particular the last decade, the Colleges have failed to keep pace with the times. They remain backward and inefficient in many things. Licensing - one of their core jobs - is one of the most backward aspects of what the Colleges do.

The fact that colleges exist because of provincial law gives politicians much more than the powers of strong persuasion to clear the bureaucratic obstacles in the Colleges that keep ordinary Canadians from getting the care they need when they need it, in the most modern and effective way possible. It’s been sad to watch the Atlantic Premiers struggle with this problem for years.

It’s also sad to see how disconnected they are from the reality. Just this year, Premier Andrew Furey told reporters that doctors “are very well trained in Canada.” he added that once “you're licensed in any [Canadian] jurisdiction, there's no reason to think that you shouldn't be able to practice medicine somewhere else [in Canada]."

Furey’s absolutely right about that. Maybe his wife - Dr. Alison Furey - didn’t have any problems getting to Ontario to help with COVID. Others are not so fortunate, if she did have an easy time. Ask any doctor who has tried to practice in a province other than the one they live and work in.

But Furey’s wrong when he also said in that media briefing that Canadians are fortunate to have “a robust licensing system that could be applied blanket-statement to the whole country.” The Canadian system isn’t robust. It’s sluggish, bureaucratic, and hidebound.

He’s also wrong if he and his colleagues are thinking the answer is to create one big bureaucracy for all of Atlantic Canada, as he told reporters after the Atlantic Canadian premiers met earlier this year. The problem is not four separate Colleges. Each College has the power to make all the decisions, including the discretion to look at a case like Paul Hart’s, recognize his education, training, and experience, and at the same time protect the public by putting a restriction on any aspect of his practice where there might be a genuine deficiency.

The problem is the attitude deeply embedded in all the Colleges across Canada that a doctor licensed in one part of Canada cannot be allowed to practice anywhere else in Canada based on the professional assessment of peer College in another province.

The problem is also in the attitude bound up in Paul Hart’s case. After all, he’s a Canadian trained doctor who has been working successfully for almost half a century in a peer jurisdiction in the United States. A poorly written form letter told Hart little except “no licence for you” but based on absurd arguments about his training and qualifications that contradict the College’s own standards of medical practice.

It’s hard to believe but then again, we are talking about a College that cannot tell the public reliably how many doctor there are in the province and that lists on its register of people eligible to practice medicine here physicians who have not practiced here in decades and many more who are long dead. The letter is not an anomaly. It’s very much the norm.

Paul Hart is one case. One we know about. Given the letter, the College’s response to the controversy, and the other administrative problems, odds are he is not alone. And on top of that we have the enormous costs of the existing system of medical licensing, one that is *not* nearly as good as Furey appears to believe.

The Premier and the health minister have the power to sort out this mess at the medical licensing authority in this province and with it a great many other problems in health care across the province that result from it. They have the bully pulpit.

They have the power and Furey himself has said the health system is in crisis.

That gives Furey the reason to act.

But will he?

Let’s see if he has the lion-heart for it or succumbs to heart failure.

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Edited and updated 19 Sep 22