“I was applying for (an Ontario) licence and it was such an ordeal that I gave up halfway through,” says Dr. Stephen Cashman, a physician with a focus on rural and remote health care who lives in Quebec City. He was planning to practise in rural Ontario but found the provincial authorization process so onerous that he abandoned the idea. “I have enough places to work, forget this.”
Cashman has made it his mission to go wherever his service is needed; he currently holds five licences — in the Northwest Territories, Yukon, Nunavut, Quebec and New Brunswick. But he gave up on Ontario when he faced having to request new copies of all the documents previously submitted to the other provincial regulators. Documents such as Certificates of Professional Conduct and exam certifications have to be requested and paid for every time a doctor applies for a licence in a new province.
The latest report by the Canadian Institute for Health Information on the state of the Canadian health workforce says 5.7 million Canadians are without a regular health-care provider. A 49 per cent increase in family physicians is needed to meet the current demand and rural and remote areas are more affected by these shortages than urban centres.
Cashman says many doctors would be willing to help an Emergency Department in another province to prevent its closing. “But not if there is a three-month lead time (they) need to send in all this nonsense paperwork,” he says.
If pan-Canadian licensing for physicians existed, Cashman would be able to go practice in whatever province or territory he feels he is needed. Instead of applying to each provincial and territorial medical regulatory authority for a licence, doctors in good standing could work anywhere in the country without facing administrative hurdles.
At least that’s what the current public discourse envisions. But the reality is much more complicated. There are potential pitfalls, as the experiences of Australia and Atlantic Canada show.
Dr. Kyle Sue-Milne of Edmonton is more hopeful than ever before that nationwide licensing will become a reality. As a physician who has worked in different provinces and territories, he has experienced the administrative burden related to provincial licensing firsthand, and has been advocating for pan-Canadian licensing since 2016 as the lead of a Society of Rural Physicians of Canada (SRPC) working group.
“But the challenge is the degree to which (the provincial medical regulatory authorities) are on board,” says Sue-Milne. Some provinces are concerned that free mobility of doctors will lead to their doctors leaving. “Newfoundland and Labrador, Manitoba, Saskatchewan, New Brunswick and Quebec lose doctors every year,” he says.
He says that in principle, all of the provinces are on board with the idea. For the first time since doctors began asking for the change, the provinces, the national regulatory organizations and Prime Minister Mark Carney’s federal government — which has publicly committed to reduce interprovincial trade barriers — have all stated their support.
Organizations such as the SRPC have long advocated for a national licence, arguing it could prevent emergency departments from closing. The SRPC emphasized this in a letter sent to federal Health Minister Marjorie Michel before she met with her provincial and territorial counterparts in October. Pan-Canadian licensing, it’s been argued, would support an overstretched rural and remote physician workforce that could benefit from short-term support from skilled physicians such as Cashman.
Still, as Sue-Milne points out, “The Canada Health Act says that health care is a provincial jurisdiction” so the legislative requirements a doctor has to meet differ from province to province. For example, membership in the provincial medical association is mandatory in some but not others. The provinces also differ in what documents and background checks they require, and have different rules regarding prescribing of controlled substances such as opioids. (In some provinces, such as Manitoba, prescribing of certain medications requires additional training and privileges.)
The easternmost provinces, in particular, are unique: Since 2023, doctors registered in one of the four Atlantic provinces have been able to sign on to the Atlantic Registry. For a fee, the information submitted for Cashman’s New Brunswick licence was shared with the other three provincial colleges, and he thus acquired licences in Nova Scotia, Prince Edward Island, and Newfoundland and Labrador without additional paperwork. The Atlantic provinces prove that pan-Canadian licensing could work, says Sue-Milne.
An analysis of the registry by researchers at Laurentian University, however, shows that the administrative burden was lessened but not eliminated: there are additional inefficiencies for the provincial regulators.
A doctor signed up for the registry still receives a separate licence from each of the four Atlantic provinces — but for small provincial regulators, the additional administrative work associated with issuing licences is a burden, says Sue-Milne, and comes with no guarantee that a doctor will come and work in their province.
“Nunavut has just one person who does everything,” he says. If pan-Canadian licencing follows the Atlantic registration model, where licensing is a manual process, small jurisdictions like Nunavut might struggle.
Sue-Milne says the current discussions centre on possibly limiting the additional licences to a few months rather than the full year granted by the Atlantic Registry. He adds that there is no consensus among the provincial regulators regarding the fee doctors should be charged for additional licences.
On the national stage, the equivalent to the Atlantic Registry is the National Registry of Physicians, a database that provides information on physicians in Canada. All provinces except Quebec and Ontario have agreed to share their information with the national registry. Ontario has not publicly stated why it has not joined, but Quebec historically has not joined interprovincial efforts regarding health care.
The Canadian Medical Association says the establishment of the national registry is regarded as a step toward pan-Canadian licensing. Still, like the Atlantic Registry, the national one is an information repository only; neither issues licences. Once an Atlantic physician has registered, the individual provinces issue provincial licences based on the Atlantic Registry’s information. Similarly, the national version does not issue licences but could let provincial regulators access information on physicians without the need for physicians to resubmit their documentation.
This contrasts with Australia’s approach. In 2010, Australia launched the National Registration and Accreditation Scheme, a national registry for doctors and other health professionals. This allowed for the creation of a national health practitioner regulation agency that issues national doctors’ licences.
Dr. Olga Ward has decades of experience in working for rural and isolated Australian communities. She says that national registration permits free movement of physician but the administrative burden increased. “I think our biggest issue was we got what we asked for — but in a format that the government wanted. That created more government control and actually more layers of administration at three times the cost to (doctors) personally.”
She says what doctors asked for was very simple — “that the state medical boards simply amalgamated their databases.” This would give a state’s medical board to access doctors’ information and decide if they are in good standing and able to work in a different state.
Instead, the registration and licensing were made national while the state medical boards, agencies and professional colleges remained, bringing requirements for things such as continuous professional development that vary from place to place.
remained. The additional national layer has increased the administrative burden, Ward says. And state regulations persist: a psychiatrist based in Queensland seeing a patient in West Australia via telehealth cannot prescribe certain medications, despite any national licence.
With a shortage in certain specialties, Ward says, “talking to burned-out female doctors Australia-wide, it’s this kind of administrative thing that is actually just leading to people retiring or reducing their hours.”
Ward and Cashman both say the fewer administrative steps to get pan-Canadian licensing, the better. They both note there is a risk that regulators will try to increase or justify their influence. And Sue-Milne emphasizes that pan-Canadian licensing requires compromise and the provinces and territories working together.
In Cashman’s ideal world: “If you have a New Brunswick licence, you could immediately go work in British Columbia.”
Nadin Gilroy is a physician and journalist based in Winnipeg and a journalism fellow at the Dalla Lana School of Public Health.
