Dr. Mike Benusic, medical resident, ER doc and spokesperson for Medical Residents of Canada poses for photos in a Roncesvalles clinic in Toronto, Ont. on Thursday, Dec. 20, 2018.

Monika Dutt has worked as a doctor in Nova Scotia, Saskatchewan, the Northwest Territories and Ontario.

Although she has been practising medicine since 2005, a combination of family medicine and public health, each move has required Dr. Dutt to go through the “frustrating and expensive” process of getting a new medical licence.

That’s because, while there is a standard set of requirements physicians need to meet to apply for a full licence to practise medicine in Canada, all 13 provinces and territories have separate licensing requirements and fees.

“The Ontario application required 42 documents, right back to my medical-school transcripts,” said Dr. Dutt, who is now the CEO of the Timiskaming Health Unit in northeastern Ontario. There were also thousands of dollars in fees.

For example, the Nova Scotia College of Physicians and Surgeons has an annual fee of $1,950, plus an additional $975 if the fee is paid after July 1. A temporary licence costs an additional $850. There are also fees to review qualifications, $550, and a documentation fee of $450. A copy of a diploma costs $75 and a letter confirming a physician is a member is $40. Physicians who do locums (temporary postings) pay $250 more a month. Other provinces have similar fees. Universities and hospitals also charge fees for documentation.

“It really adds up,” Dr. Dutt said.

She said she understands why rigorous licensing is necessary – “to weed out the small number of physicians who have done awful things” – but it is not clear why the provinces and territories don’t recognize each other’s licences.

Dr. Dutt is not alone in asking that question. A growing chorus of medical groups – including the Canadian Medical Association, Resident Doctors of Canada and the Canadian Federation of Medical Students – are pushing for some form of national licensing.

After all, training is similar in Canada’s 17 medical schools and in residency programs across the country, and patients are not appreciably different.

The physician groups pushing for change argue requiring separate licences in every jurisdiction makes it difficult, and sometimes impossible, for physicians, particularly in rural and remote parts of the country, to find doctors to fill in for them while they’re on holidays or when they wish to reduce their hours as they grow older.

The onerous licensing rules also discourage interprovincial co-operation – for example, a Vancouver orthopedic surgeon can’t easily go to St. John’s to do hip replacements, even if there is a desperate need.

“The current fragmented system doesn’t just create annoyance for physicians, it creates real barriers to patient care,” Mike Benusic, the lead on national licensing for Resident Doctors of Canada, said in an interview. He said RDC believes the onerous relicensing provision is an unfair restriction on labour mobility and, as such, violates the Canadian Free Trade Agreeement.

He splits his time between working as a public-health resident in Toronto and lending a hand in family practice in rural Alberta – which means having two licences.

Like many young physicians, he does locums in clinics or hospitals, often on weekends and holidays.

“Locums allow you to check out places, to see if you would like to practise there. They also pay well, so you can pay off some student debt,” he said.

Locums are also an important recruitment tool, especially for rural and remote communities, who use them to woo doctors.

According to a survey by Resident Doctors of Canada, 18.5 per cent of medical residents say, once they are in practice, they are planning to do locums in another province or territory. But 52 per cent said they would do so if it did not require the hassle and expense of getting additional licences.

Dr. Benusic understands the hesitancy. He was asked to help out temporarily in a family practice in rural British Columbia, but realized the licensing process would take months and bring additional costs. A B.C. licence costs $1,700, requires a criminal record check and a plethora of other documents.

“Meanwhile, there were 800 patients waiting for care,” he said. “So who are these rules serving?”

Linda Inkpen, president of the Federation of Medical Regulatory Authorities of Canada (FMRAC), which shares best practices among jurisdictions, said regulation is a provincial/territorial responsibility in medicine, just as it is in law, engineering and other fields, and that’s not going to change.

“Constitutional issues put up major barriers to the idea of a national licence,” she said in an interview. Dr. Inkpen added, “it’s also not clear how much it’s really needed either.”

While there are surveys showing what physicians might do in theory, there’s very little data on how many actually practise in more than one jurisdiction.

The CMA, in a small survey, found 10 per cent of physicians were licensed in more than one province or territory. But only 1,300 of the country’s 80,000 physicians were surveyed, and those who responded are likely those most interested in the issue of national licensing.

Some physicians feel the colleges are merely protecting their turf and their income by maintaining separate regimes in each jurisdiction, but Dr. Inkpen said that is unfair. “We are there to uphold standards and we take that role seriously,” she said. (However, the standards are more or less the same in every province and territory.)

She added provinces and territories “hold regulatory bodies very close to their chest,” as demonstrated by the lengthy federal-provincial battle over a national securities regulator.

Dr. Inkpen said FMRAC has spent considerable time and effort breaking down provincial barriers, spurred by the Canadian Free Trade Agreement that come into force in 2017. For example, the application process is now similar in each province and territory.

FMRAC, in conjunction with the provincial and territorial regulators, is looking at some sort of “trusted physician licence” (similar to a Nexus card for frequent flyers), which would provide expedited clearance for physicians to work temporarily in other jurisdictions.

But that falls short of the “portable locum licence” that the residents’ group is looking for.

“The mandate of regulatory authorities is to protect the public – and we support that fully,” Dr. Benusic said. “But we think a single licence would do that as effectively – maybe even more effectively – than separate licences in every jurisdiction.”