We want to come home


Viktoria Koskenoja is an emergency medicine resident in her fourth year of the Harvard-Affiliated Emergency Medicine ResidehaleyKcochranency


Haley K. Cochrane is  an emergency medicine resident in her second year of the Harvard-Affiliated Emergency Medicine Residency


We are Canadian women, born and raised in northern Canadian communities. We are both training to be emergency physicians at the Harvard-Affiliated Emergency Medicine Residency in Boston. While we would like to come home, there are only massive barriers before us.

There is a known scarcity of emergency physicians (EPs) in Canada. The combination of physician shortages, as well as a concentration of specialists in urban centers, has led to regions where up to 70 percent of ED providers have no formal emergency medicine (EM) training. “With a national shortage of trained emergency physicians, most Canadians will continue to have their emergency care delivered by family physicians,” states the Canadian Association of Emergency Physicians, “[with] no guarantee that the family physician staffing a community ED will have adequate training in the management of actual emergencies or in resuscitation.” In recognizing these workforce issues, the CAEP recommended increasing residency spots for CCFP (EM) and FRCP-EM programs as well as increasing the use of mid-level providers. But what about a simpler, more cost-effective option—allow U.S. trained EPs to return to Canada?

Currently the pathway home is long, arduous, and expensive, although it does technically exist. The only option allowing unrestricted practice in Canada is to become board certified by the Royal College. Because EM residencies in the U.S. are only three to four years long, versus five in the FRCP-EM pathway, extra training is required to bring U.S. residents up to Royal College’s standards. But this is not so simple. Fellowships in the U.S. are a possible route to satisfying the fifth year requirement, but many fellowships are longer than one year and even then may not meet the requirements established by the Royal College. The additional training gets one’s foot in the door, but there is still further to go. After taking the U.S. boards at a cost of over $2,000 (USD), the additional training is subject to assessment by the Royal College followed by writing the Royal College exams—all at a cost of over $5,000 (CAD).

In Ontario, there is a “Third Pathway” that allows U.S. trained doctors to obtain a limited license. The physician is supervised for a year and then, after an assessment, can obtain an Independent Practice Certificate. However, this pathway requires full U.S. specialty board certification as well as upwards of $9,000 CAD in fees. There are similar limited license programs in three other provinces—Alberta, Saskatchewan and Manitoba. However, the eligibility, supervisory requirements, and cost vary considerably between these programs. None grant eligibility to work in other provinces or to sit for the Royal College exams.

These two pathways to licensure differ greatly from those of Family Medicine, as set out by the College of Family Physicians of Canada (CFPC). The CFPC states it is “particularly interested in developing standards which can be used to assess training in countries outside our own, and hopefully expedite licensure for practice.” They consider the U.S. an approved jurisdiction, allowing U.S.-trained, board-certified family doctors to work in Canada with no further examinations or evaluations. By recognizing the similarities between U.S. and Canadian training, the CFPC has removed barriers to licensure which can only help with a workforce shortage.

Similarly in Emergency Medicine, with the parallels between Canadian and U.S. training programs, it is unnecessary to require additional training and assessments to work in Canada. While FRCP-EM residents do have more required time in critical care settings, U.S. residents in four-year programs are required to work more months in both the ED and pediatric EDs. It is more difficult to compare to CCFP(EM) training due to lack of published EM and critical care requirements. However, based on the length of overall training, U.S. residents likely spend more time in the ED and critical care settings. Because of the similar training, there is no reason to suspect that residents graduating from a U.S. program would be ineffective in Canadian EDs. In fact, merging the practice cultures could present opportunities for exposure to new practice patterns and evidence-based protocols. Increasing the number of EPs in Canada would also improve the public’s access to emergency specialists and reduce the costs associated with sending locum tenens physicians to under-served areas.

With the cost and prolonged timeline needed to practice in Canada, few U.S.-trained Canadians are likely to return. As noted above, the main problem is obtaining provincial licensure, as all provinces require CCFP(EM) or FRCP-EM training (with the exception of the few provincial alternative pathways). The simplest way to remove the barriers would be to allow U.S. board- certified doctors to obtain licenses in any provinces where more EPs are needed. Reducing fees and attracting residents immediately following their training would establish them in the Canadian EM community and allow provinces to fill gaps in ED coverage with qualified specialists.

Canada needs more EPs and we want to work in Canada. Many Canadians training in the U.S. are interested in returning home but the extended timeline and litany of fees creates a burden that few are willing to bear. Instead of waiting for funding to train the needed EPs in Canada, clearing the path for U.S. trainees to cross the border seems like a sensible solution. Creating a more streamlined system for obtaining provincial licenses would benefit not only the U.S-trained residents, but the provincial health systems and the Canadian public. In the only published article on Canadians training in U.S. EM residencies, the author states, “The U.S. training route appears to be underutilized given the limited number of Canadian training positions and the Canadian EP workforce shortfall.” We couldn’t agree more.

16 thoughts on “We want to come home

  1. Yankee Jane, MD

    This blog post raises the question of concerning political tactics by the Royal College. Is it a calculated approach to prevent American EPs from encroaching on their power? Also concerning bc this would imply the Royal College believes it can more easily control CCFPs & midlevels - a clear insult to those they say provide equivalent care. Could it be that fear of losing power matters more to the Royal College than the health of Canadians?

  2. Dr. Max

    I would be more concerned that providers who never received adequate Emergency Medicine (EM) training are out there providing sub-par, 'good enough' EM while patients suffer.

    Sure enough you can spend years in the Emergency Dept without ever noticing you're doing anything wrong, and parents, patients, families often can't tell one doctor apart from another, but as EM specialists we often can... and if I may paraphrase Socrates: you don't know what you don't know.

    It's just not fair that one patient receives the standard of care EM excellence, while another receives the patch-up medicine variety.

  3. Dr. Maple Leaf Resident

    If you chose to pursue training in another country, you shouldn't be shocked that there are licensing restrictions to practice in our country. Canadian residents write those same expensive exams you are complaining about.

    As a Canadian specialty (non-ED) resident that is soon facing graduation with no job prospects beyond Fellowship, I have little sympathy for residents who didn't have the foresight to look into licensing restrictions before undertaking a massive career decision. There are programs to allow foreign trained physicians to work in under serviced communities, if that is what you truly wish to do. If you want to slide into an urban position in a major city, though, get in line with everyone else.

  4. Viktoria Koskenoja

    Dear Dr. Maple Leaf Resident,

    I am sorry that you are facing a difficult job market for your specialty.

    Your comment about allowing foreign trained physicians to work in underserviced communities is puzzling. We addressed that in the blog post, but contrary to what you imply, that process is still very expensive and complicated. It's not actually a smooth path to working in rural areas vs. a line for competitive urban jobs. I have no interest in working in an urban area, and it would still take 3 years post-residency and cost over $9000 to be certified to work in my home town in Ontario.

    As we wrote the the post, for specialties with shortages (family medicine, emergency medicine), it makes sense to loosen restrictions on physicians with similar training. Family medicine has already done it.

  5. James knight

    I'm a Canadian 1st year EM resident in the US as well. Has there been any progress regarding this? I feel if more people knew about this we could potentially ignite some change

  6. Viktoria Koskenoja

    Hi James,

    No progress yet. I ended up accepting a job in the U.S .It would be great to bring together the U.S.-trained Canadians somehow to share resources on how to return to Canada.

  7. Darcy Mainville

    Does anyone know if a critical care fellowship that follows a US three year EM residency makes this transition back more or less possible? I haven't been able to find anything that clarifies how or what would be required to add to a US 3 year EM residency to be considered "equivalent" training. Would love to talk to someone that's actually done it but I haven't found that either. I appreciate this discussion, there isn't much out there that discusses this.

    1. Viktoria Koskenoja

      Hi Darcy, to get specific information you have to email the Royal College but even then you often won't get a straight answer of what counts until you've already done it. I haven't met anyone who has done that pathway, I think you might be limited in your required peds exposure if you take that route. All the info I've gotten has been from a handful of people who did fellowships in the U.S. or extra training in Canada.

  8. Dr. Dan

    Darcy - My impression is that the Royal College will only accept one year of fellowship training. Meaning that in order for the Royal College to consider allowing you to sit for the boards you need to come from a 4 year program and do a one year fellowship. I looked into this a couple of years ago and there was no pathway via the Royal College for a US EM physician who came from a 3 year residency program to become board certified in Canada (short of repeating your residency in a 4 year program and then doing a 1 year fellowship). Dan

  9. M.D.

    I don't feel your article's backdrop, of poor Canadians unable to return home, is very believable, or your arguments to be very compelling, which I would divide between "silly" and "incorrect."

    Your mention of the costs to return to Canada falls in the category of "silly," as spending some thousands on exams and licensing is required of everyone, and is hardly unique to you or anyone else. And as you would be entering the workforce 1-2 years earlier than your Royal College colleagues, one would actually state that you are coming out vastly ahead financially, as those colleagues are still earning a trainee salary while you make 5 times that.

    Among your comments that fall in the category of "incorrect," include that "the only option allowing unrestricted practice in Canada is to become board certified by the Royal College." As you have noted, Ontario allows a restricted license with only U.S. Board certification, which becomes a full unrestricted license after 1 year. Some other provinces allow a full unrestricted license straight off with just the MCCQE 1&2 and U.S. Board certification. I personally have never then found a hospital in Canada that wouldn't accept ABEM certification in lieu of Royal College certification for credentialing.

    Bemoaning however the injustice of having to have a restricted license for a year, if going the Ontario route, falls in the category of "silly." During this time, you make full pay, and the supervision is along the lines of someone just filling out some paperwork. Of course, if having a restricted license for a year is so distasteful, you can get licensed in a province that will give you full registration, and then get a full Ontario license through the AIT. Look it up if you're not familiar with that.

    Your comment that "few U.S.-trained Canadians are likely to return" due to the "long, arduous, and expensive" process, is hence a statement I hence would categorize as "silly." Both of us are speaking wholly anecdotally, of course, but the people I have known who wanted to return to Canada, have gone through the process and returned to Canada. In my opinion, anyone with the most tepid desire to return, and have U.S. Board certification and Canadian citizenship, should find it a very accommodating and reasonable process.

  10. David Schindler, M.D.

    I don't understand. I'm a US trained EM physician who did the "third pathway" and work in Ontario. I had no problems with the transition or licensing, except that it took a long time. I did a 4 year residency in EM (Also Boston, but BU). They never bugged me about a 1 year fellowship. Is it because I had 10 years of EM practice experience that they made it so easy? (Practicing less defensive medicine, not so easy) It's not clear to me why Viktoria, et al has a problem, unless she's not willing to do the third pathway program. I actually am allowed to bill the FRCP rate, which doesn't make much of a difference except when I am seeing consults.

  11. US EM MD

    Dear M.D.:
    "Some other provinces allow a full unrestricted license straight off with just the MCCQE 1&2 and U.S. Board certification."

    can you clarify this...?

    so is it not possible to come back to Canada with a 3 year EM Residency... it has to be 4 year + 1 year fellowship?

  12. V.H.S.

    As an older Canadian gentleman who has been considering going to med school in the U.S., one of the themes that has come up a few times in my research is the desire for US schools, especially if your education was funded by them, to keep the physicians local for at least some period of time since the school/system has invested so much time (and likely, money) in training you, as well as giving you you a spot when they could have given it to an American who is much less likely to leave the country. So the roadblocks in that sense may not be too surprising, though one would think completing your residency should adequately serve as "doing your time", but I'm just an outsider looking in, trying to make sense of it.

    Hopefully you ladies found your way back home by now, or at the very least, things are well wherever you are.


  13. V.H.S.

    I forgot to ask - if you were given the choice to do it all over again, would you still have chosen going to med school in the US, or would you have gone to a Canadian one? I'm making the assumption here that a Canadian med school would have been a possibility.

    Thanks in advance!

    1. Viktoria Koskenoja

      Updates- Dr. Cochrane completed a 5th year of residency at a Canadian program and has passed the Royal College exams so she can work in both Canada and the U.S. I took a job in the U.S. located close to the border so I can visit my family easily. Regarding if I would have chosen to go to med school in Canada, it's hard to say. I'm happy in my current situation but would love to have more flexibility to work in Canada in the future.


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