Picture of Viktoria Koskenoja

Viktoria Koskenoja is an emergency medicine resident in her fourth year of the Harvard-Affiliated Emergency Medicine ResidePicture of Haley K. Cochranency


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.