Regulations for Practicing in Canada
Retina specialists who train in the United States and wish to practice in Canada have a couple of hoops to jump through.
I recently completed a retina fellowship at Wills Eye Hospital in Philadelphia. Unlike the other fellows in my program, however, I am a Canadian citizen, and so, when I departed Wills to begin my professional career at the University of Ottawa Eye Institute, a few of my curious colleagues asked me about the qualifications to practice in Canada. Are Canadian qualifications similar to US qualifications? Specifically, what regulatory requirements must a US-trained physician meet in order to work in Canada? In an effort to improve cross-border understanding, here is a brief overview of what Canada requires of foreign-trained physicians who wish to practice in the Great White North. I invite you to kick back, pour yourself a Molson, have some poutine, and delve into these requirements.
Retina specialists who wish to practice in Canada should be aware of the differences between the structures of the Canadian and US health care systems. These differences, though slight, are important to understand.
INDEPENDENT MEDICAL LICENSE
Just as a state medical license is required in the United States, a provincial medical license is required in Canada. In order to reduce barriers for qualified US physicians wishing to practice in Canada, significant policy changes were effected in 2008 that have streamlined the process of acquiring a provincial medical license. Applicants must have obtained an MD degree from a medical school accredited by the Liaison Committee of Medical Education or a DO degree from an osteopathic medical school accredited by the American Osteopathic Association.
Applicants are also required to have successfully completed a residency program accredited by the American Council for Graduate Medical Education. Before 2008, US-trained physicians were required to undergo an additional year of residency training before practicing in Canada. This requirement was set in place because Canadian physicians participate in 4 years of residency training versus 3 in the United States. After rule changes in 2008, however, the fourth year is no longer required.
Applicants must have successfully completed all steps of the US Medical Licensing Examination; applicants are no longer required to pass the Canadian equivalent to the US Medical Licensing Examination. Applicants must also be specialty board certified in the United States; Canadian specialty board certification is no longer mandatory. Additionally, all applicants must hold an unrestricted medical license to practice in the United States.
If these criteria are met and a registration committee approves an application for registration, a certificate of registration will be issued. Once it is issued, the physician can begin to practice, although he or she must do so alongside a mentor or supervisor until the physician passes an assessment by the licensing body. This assessment can be completed only after a minimum of 1 year of practice; it is required to ensure that applicants are practicing competently and safely.
In Canada, most physicians obtain medical liability protection through the Canadian Medical Protection Agency. This is a not-for-profit organization that provides medicolegal advice and liability protection for all physicians in Canada. Fees vary based on the physician’s specialty (eg, surgical vs medical) and the province in which the physician works. This fluctuation in fees reflects the risks inherent in different types of practices and the regional variations in medicolegal costs. There is no Canadian equivalent to the Ophthalmic Mutual Insurance Company or to institution-based liability coverage, which is common in the United States. Individual physicians in Canada must have individual liability insurance. The criteria to obtain such insurance are no different for US-trained physicians compared with those trained in Canada as long as the applicant produces a medical license and is shown to have a clean history.
PROVINCIAL BILLING NUMBER
Medical billing in Canada is generally simpler than in the United States. Canada is effectively a single-payer health care system. After obtaining an independent provincial medical license and a practice address, the physician must register with his or her province to obtain a unique billing number. Physicians have to get credentialed with only 1 provider covering all of their patients that will be the single point of contact for remuneration, the amount of which is based on services rendered.
Canada diverts from a single-payer system when it comes to medications. Some medications, including certain intravitreal injections, may not be covered by provincial health care plans. Drug coverage determination depends on the province, the indication, and the patient’s age. As such, many patients choose to obtain supplemental insurance from a private company to defray costs not covered under the single-payer health care system. This is particularly relevant to retina specialists who must submit applications to various insurers to obtain drugs such as the dexamethasone implant (Ozurdex, Allergan), aflibercept (Eylea, Regeneron), or ocriplasmin (Jetrea, ThromboGenics). A physician who has practiced in the United States would likely be familiar with this process.
DIFFICULTIES TO CONSIDER
The above points outline only basic steps required, primarily from my experience in the province of Ontario. Applicants should contact the respective institutional bodies within each province for detailed requirements. All other details (for instance, obtaining hospital privileges) should not be precluded based on having trained in the United States. Retina specialists wishing to practice in Canada need to be concerned about more than just licensing and credentialing. Current practical issues for a retina specialist wishing to practice in Canada include the constraints of hospital budgets and the associated paucity of available OR time. Retina surgery in Canada is funded entirely by the government and is largely hospital-based (although ambulatory surgical centers capable of taking on retina cases have emerged in some provinces). Government funding, which dictates hospital resources, is limited. As such, many of the specialties within a hospital must share these resources. Even though increased OR efficiency has helped stabilize wait times for patients despite tightening budgets, the availability of additional OR time for new physicians is essentially capped. In fact, given the limited available resources, many Canadian surgeons who have recently graduated find it difficult to secure surgical time. Difficulty in obtaining OR time would undoubtedly be a significant barrier for any retina surgeon wishing to practice in Canada at this time.
There is 1 other thing, arguably the most important, which an American physician must have in order to practice in Canada: the ability to tolerate the word “eh,” often used multiple times in a single conversation. However, I hope that my co-fellows can attest to the fact that this gets easier with time, and that Americans and Canadians may not really be that different in the end. Ultimately, perhaps that is what this article is all “aboot.”
Michael Dollin, MD, FRCSC, is a recent graduate of the vitreoretinal fellowship at Wills Eye Hospital and is joining the faculty at the University of Ottawa Eye Institute in Ottawa, Ontario, Canada. Dr. Dollin may be reached at firstname.lastname@example.org.