Where does our duty lie?
CMAJ 1997;157:1740
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In his recent letter "Foreign specialists need not apply" (CMAJ 1997;157[7]:869-70 [full text]), Dr. Shabbir Alibhai discusses the decision by the Royal College of Physicians and Surgeons of Canada to recognize only training taken in accredited residency programs in Canada and the US and raises some important questions about this decision.
The college's accreditation process is very different from that applied in most countries. Although it is un-Canadian to consider anything from Canada the best in the world, in the case of accreditation of postgraduate training it happens to be true. Indeed, most countries do not accredit residency programs. Some, such as the United Kingdom and Saudi Arabia, are developing systems modelled to some degree on ours.
As long as there is no generally accepted measure of competency to test physicians from around the world, no study to demonstrate differences between countries can be undertaken. However, the relative performance of trainees of different origin on examinations has been studied. At one time the college allowed a broad spectrum of candidates to take its examinations. Failure rates in certain groups exceeded 90%, and we were criticized for "exploiting" candidates who went to great expense with little chance of success. The college then decided that examinations should be limited to those expecting to practise here and those who would likely succeed because of previous evaluations in accredited programs. This is another distinguishing characteristic of the Canadian system: success in examinations does not in itself confer certification. Evaluation during training plays an increasingly important role.
For more than a decade, only candidates trained in Canada, the US, the UK, Ireland, South Africa, Australia and New Zealand have been allowed to take Royal College examinations. Our recent change has decreased the number of foreign exemptions to 1: the US. The college does hope to see increasing reciprocity in accreditation. A formal offer has been made to sister colleges in many of the countries noted above. As well, the Royal College sponsored an October symposium that brought together key players in an attempt to find a way to evaluate and recognize offshore specialists recruited to remote areas.
But I have some questions of my own. Why do we, as Canadians, collectively throw up our hands and presume that we can never overcome the inadequate distribution of medical specialists? With all of our advantages, why should Canada not be a net exporter of highly trained specialists instead of an importer? And what of young Canadians and their desire to pursue a career in medicine? There is less than 1 first-year place in medical school available for every 20 000 Canadians. The only other country with such a low number is Albania! In BC the ratio of first-year positions to population is 1:26 000. In the UK, a commission has determined that the ratio there should be increased to 1:13 500.
I fully agree that as citizens of the world we have moral obligations to specialists everywhere, but surely our first duty is to Canadians.
Hugh M. Scott, MD
Executive Director
Royal College of Physicians and Surgeons of Canada
Ottawa, Ont.
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