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Assessment of International Medical Graduates and Their Integration into Family Practice: The Clinician Assessment for Practice Program

Maudsley, Robert F. MD

doi: 10.1097/ACM.0b013e318163710f
International Medical Graduates

The Clinician Assessment for Practice Program (CAPP), a program of the College of Physicians and Surgeons of Nova Scotia (CPSNS), assesses the readiness for family practice of international medical graduates (IMGs) who have trained and practiced abroad with no formal Canadian residency training.

CAPP has three parts. Part A, a therapeutics exam and an objective structured clinical examination, assesses practice readiness. Part B is a 12-month mentorship in which the CAPP physician is in active practice under a defined license and is mentored by an established family physician. The mentor provides teaching, supervision, guidance, and regular performance assessment. Each CAPP physician negotiates an individualized continuing medical education plan. An on-site assessment of each CAPP physician's practice is conducted by an external assessor who provides feedback to the CAPP physician and his or her mentor. Multisource feedback is administered at 10 months, using questionnaires from patients and colleagues. After 12 months, all assessment data are reviewed by the CPSNS to determine whether to continue the defined license. Part C, run by the registration department (not CAPP), may last three additional years until full licensure is obtained.

To date, 148 IMGs have been assessed, 35 have been deemed eligible for a defined license, and 27 have entered family practice, virtually all in small or medium-sized communities in Nova Scotia. The program has been well received by participants and their communities. The mentorship, particularly valuable in assisting IMGs to integrate into their communities, has proven to be the defining feature of CAPP.

Dr. Maudsley is executive director, Clinician Assessment for Practice Program, College of Physicians and Surgeons of Nova Scotia, Halifax, Nova Scotia, Canada.

Correspondence should be addressed to Dr. Maudsley, College of Physicians and Surgeons of Nova Scotia, Suite 200, 1559 Brunswick St., Halifax, NS B3J 2G1,Canada; telephone: (902) 482-2915; fax: (902) 422-7476; e-mail: ( or (

Some developed and many developing countries do not produce and retain a sufficient number of physicians to meet their medical care needs. Canada relies on international medical graduates (IMGs) to contribute to the physician workforce; currently, 23% of Canadian physicians obtained their medical degrees from outside Canada.1 In the United States, 25% of the physician workforce are IMGs.2 In the United Kingdom and Australia, IMGs represent 28% and 26.5%, respectively, of the physician workforce. Lower-income countries supply between 40% and 75% of the IMGs to these four countries, with India, the Philippines, and Pakistan being the leading sources.3

In 2003, the College of Physicians and Surgeons of Nova Scotia (CPSNS) investigated the feasibility of establishing a program to assess IMGs wishing to enter family practice in Nova Scotia. During the previous decade, the CPSNS had referred IMGs to the University of Manitoba assessment program. After 2004, the University of Manitoba program was no longer available to IMGs in Nova Scotia because of increased demand (the Manitoba program was used to assess the IMGs of its own province as well as those of Saskatchewan). The establishment of a new program offered an opportunity for addressing some of the issues that had concerned Nova Scotia IMGs and physicians when they used the Manitoba program.

During the years when the CPSNS still had access to the Manitoba program, IMGs were required to identify an established, willing physician sponsor in Nova Scotia before being assessed. Many of these established physicians were reluctant to commit to being a sponsor until they knew the IMG was licensable. Also, the quality of sponsorship varied considerably. Some sponsors were especially attentive to the learning needs of their IMGs, whereas other sponsors spent little time in the supervision or guidance of theirs. The establishment of a new program offered an opportunity to address some of these concerns. Therefore, the designers of the Nova Scotia program convened two focus groups: one of previous sponsors, and the other of IMGs who had been successfully sponsored by a physician, assessed by the Manitoba program, and were now in active family practice in Nova Scotia. From the focus groups, it was evident that a more formalized process of support, supervision, and evaluation was necessary to strengthen and regularize defined licensure. Thus, we developed a mentorship model in which the mentor plays a more active role during the first year of defined licensure.

Across Canada, there are several other provincial IMG assessment programs for family physicians and specialists; however, according to a popular Internet site, all of these are focused on determining IMG suitability for Canadian residency training.4 In contrast, the Nova Scotia program has been initially limited to determining practice readiness for two reasons: first, there were virtually no residency positions available to IMGs in Nova Scotia; and, second, we believed that some IMGs are indeed ready for clinical practice but still require initial support and guidance to adapt to family practice specifically in Canada.

This article describes the program developed in Nova Scotia to assess and integrate IMGs into family practice, and the experience of the program to date.

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Program Model

We developed a model that could be readily adapted to assessing international graduates of other health care professions as well as IMG physicians and that could be made widely available to professional licensing authorities. Although the initial focus was on the assessment of family physicians, we maintained the concept of a more broadly applicable model with emphasis on practice readiness—hence the name, the Clinician Assessment for Practice Program (CAPP). A three-part CAPP model evolved (see Figure 1). Part A is a stand-alone assessment component for IMG referrals who have applied to any medical licensing authority. For those IMGs who are granted a defined license to practice family medicine in Nova Scotia, this assessment becomes an integral part of their overall program along with parts B and C, which are both based on the premise that although newly licensed IMGs are considered practice ready, they lack formal Canadian residency training and experience. To compensate, Part B is a 12-month program of continuing professional development, with ongoing support, guidance, and evaluation by a physician–mentor as well as assessment at 6 and 10 months. Part C, which may extend up to three years beyond Part B, is essentially managed by the registration department of the CPSNS, rather than CAPP.

Figure 1

Figure 1

CAPP accepts referrals from medical regulatory authorities of IMGs who are citizens or permanent residents of Canada, who have graduated, trained and practiced abroad (for at least three years, including both training and practice), and who have successfully completed both the Medical Council of Canada Evaluating Examination (MCCEE), a screening examination for IMGs, and the Medical Council of Canada Qualifying Examination Part I (MCCQE I), an assessment of competence for entry into supervised clinical practice with respect to knowledge, clinical skills, and attitudes. Some CAPP candidates have also completed the MCCQE II (an OSCE assessing competence for medical licensure in Canada). (The other candidates must also eventually complete this examination to earn full licensure; they can attempt to do so during their first year of practice.) A formal test of English is not required. Provincial medical regulatory authorities may require other prerequisites before referring an IMG to CAPP; for example, Nova Scotia requires IMGs to have been in clinical practice within the last five years.

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The Three-Part CAPP Program

Part A: Initial assessment

Part A has two components: a written therapeutics examination, and an Objective Structured Clinical Examination (OSCE). (All candidates’ general medical knowledge has been assessed by the initial, required MCCEE and the MCCQE I.) The therapeutics examination, three hours in length, uses a 50-item short-answer format, with nearly all questions related to a brief clinical scenario. The test assesses domains of pharmacotherapy, adverse effects, disease prevention, and health promotion for people of all ages from infants to older adults. Also incorporated into the examination booklet are several blank prescription forms that candidates must complete on the basis of the clinical scenario. Candidates are assessed as to whether their prescriptions, as written, are appropriate and could be safely and efficiently filled by a pharmacist.

The second component, the OSCE, is developed and conducted in close collaboration with the Learning Resource Centre (LRC) of the Dalhousie University Faculty of Medicine. It is designed to simulate a half-day experience in a typical family practice clinic, and it comprises 14 stations, which are each 10 minutes in duration. Some cases are taken from the LRC case bank (an archive of cases used to assess medical students and residents) and modified to assess practice readiness; other cases have been developed specifically for CAPP by family physicians. The LRC staff select and train standardized patients to follow detailed scripts. The OSCE examiners, family physicians in active practice throughout Nova Scotia, are trained in a mandatory half-day workshop. During the OSCE, the physician examiners assess various clinical skills, including clinical reasoning and decision making as well as English proficiency as it relates to the clinical encounter. Standardized patients provide a more detailed assessment of CAPP physicians’ communication skills and spoken English. Because some candidates may have had little or no experience with an OSCE, a 10-minute video orientation of a CAPP OSCE is included on the CAPP Web site (, and candidates attend an orientation session on the day preceding the examination, to become familiar with the exam setting and OSCE protocol.

Results of the Part A assessments are reported to the candidate and the referring medical regulatory authority in a comprehensive, mainly narrative format, emphasizing strengths and areas requiring improvement. The report of candidates’ OSCE performance does not provide exact numerical scores; rather, candidates are divided into quintiles based on performance, and the candidate's placement is included in the report. The OSCE report, prepared by the chief examiner, contains commentary on the CAPP candidate's skills in history taking, physical examination, diagnosis and problem definition, investigation and management, clinical reasoning and decision making, communication, spoken English, and professional/ethical behavior. The OSCE report also provides information on the candidate's knowledge of public health/medicolegal and safety issues. Finally, the report includes global ratings (an overall assessment by the physician examiner at each station) of the candidate. The report for each candidate, typically 7 to 10 pages in length, serves to assist candidates in their continuing professional development.

For candidates who have applied for licensure in Nova Scotia, the Part A assessment, along with information about previous training and experience, is considered by the credentials committee of the CPSNS, which decides which candidates will be granted a defined license and move on to Part B. A defined license is granted to physicians not meeting all requirements for full licensure. (Requirements for full licensure [not an option available to candidates at this stage] are holding both the licentiate of the Medical Council of Canada and certification in family medicine or a specialty by a Canadian certifying body.) This defined license is subject to conditions or limitations and is reviewed annually by the CPSNS.

Candidates not successful in obtaining defined licensure may request that their report be forwarded either to the Canadian Resident Matching Service in support of an application to a residency program or to other provincial medical regulatory authorities. Candidates unsuccessful in qualifying for defined licensure are not permitted to take the CAPP assessment again without evidence of some additional training/experience, such as six months in a supervised general practice setting, approved by the CPSNS.

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Part B: Defined licensure

Sponsors and mentors.

Each CAPP physician (defined licensee) must have a sponsor and a mentor as a condition of the defined license. This mentorship provides an opportunity for CAPP physicians to learn and experience family practice in Nova Scotia, with the coaching and facilitation of an experienced family physician. It is designed to ensure that CAPP physicians are competent, have support when they establish practice, and are integrated into the local community.

The CAPP physicians select potential practice opportunities in communities needing family physicians, as determined by the provincial department of health (DOH) and the nine provincial district health authorities (DHA). Before mentors are assigned, travel and accommodation arrangements are made by the DOH for CAPP physicians to visit selected communities and practice sites and to meet with potential mentors and local DHA officers.

The roles of the both the sponsor and mentor are described in the CPSNS regulations.5 Sponsors are designated by DHAs and must have full registration with the CPSNS. Most are the medical directors/chiefs-of-staff of the DHA. The sponsor proposes to the CPSNS a mentor for the CAPP physician.

Before the CAPP physician establishes a formal relationship with a mentor or sponsor, he or she works under the supervision and observation of the proposed mentor for two to four weeks to determine compatibility. If all parties are agreeable, the CPSNS is notified, and defined licensure is formalized.

The approved mentor must have full CPSNS registration, be engaged in a scope of practice comparable to that of the CAPP physician, practice in the same DHA, report regularly on the CAPP physician's performance, and notify the CPSNS promptly if concerns about the CAPP physician's practice arise.

Each sponsor and mentor is provided with his or her CAPP physician's Part A assessment; an outline of the physician's previous training and experience (self-reported); and a procedural skills inventory of office and minor surgical procedures, noting training, experience, and confidence in performing such skills as providing pap smears, suturing minor lacerations, taking arterial gas samples, and applying simple casts.

Mentors receive a comprehensive manual when they attend a mandatory two- to three- hour workshop conducted by the mentorship coordinator. Initially, this one coordinator meets individually with each CAPP physician to discuss Part B of CAPP, including the mentor's role as well as assessments by the mentor and others. The coordinator is readily available by telephone to both the mentor and CAPP physician and also travels to the practice site to assist with difficult issues or problems, if necessary.

All mentors receive a monthly stipend for 13 months, with the expectation that they will spend four to five hours per week in direct contact with their CAPP physicians.

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Continuing medical education.

All CAPP physicians are referred to Dalhousie University's continuing medical education (CME) office at the outset of Part B for development of an individualized educational plan (IEP) based on the Part A assessment, previous training and experience, and the context of the new practice. A CME faculty member, an active clinician, is available as a resource throughout the mentorship, serves as the CAPP CME coordinator, and develops, with each CAPP physician, his or her IEP. This IEP is shared with the mentor and the mentorship coordinator. The overall goal of the CME component is to assist the CAPP physician in a learner-centered approach to continuing professional development based on the model of the reflective practitioner.

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First-year assessments.

The mentor not only facilitates progress and learning, but also evaluates the physician's performance providing progress reports at months 1, 2, 4, 6, 8, 10, and 12 to the CAPP physician, his or her sponsor, and CAPP administration. The categories of the reports are generally parallel to the Part A assessment so that previously identified strengths and weaknesses are the focus of the evaluations. Commentary is also provided on areas such as consultation and referral, record keeping, time management, professionalism, willingness to learn and change, and working collaboratively. The mentor uses a five-point scale ranging from performance is “above” to performance is “significantly below” that of an established physician (one who is settled in the community; conducts an active medical practice; and has gained the confidence of patients, medical peers, and other, non-medical coworkers) to assess the CAPP physician. The mentor notes both the basis of the assessment, such as direct observation or chart review, and the confidence he or she has in the rating depending on the number and duration of the assessments. The CAPP physician completes both a brief self-assessment of perceived progress and an evaluation of the mentor relationship. The mentorship coordinator reviews all progress reports as received and follows up with mentors and physicians.

An integral component of Part B is an on-site assessment of the physician's practice after four to six months. This timing allows the physician to develop a reasonable volume of patients, yet it is early enough to effect improvement of any identified deficiencies. A CAPP external assessor, an active family physician who has received instruction specifically for the role, evaluates the CAPP physician's practice. The assessor receives the Part A assessment, a summary of previous training and experience, the procedural skills inventory, and the CME plan before the scheduled visit. The assessor operates under the CPSNS regulations with respect to peer review, which provides authority to review patient files and to comment on the quality of care provided while maintaining confidentiality and receiving indemnification from legal action by the physician. Spending three to four hours on-site, the assessor reviews the operation of the practice and physical facilities, conducts an audit of 25 randomly selected charts and a chart-stimulated-recall interview, interviews office staff as appropriate, meets with the mentor to discuss the CAPP physician's progress, and provides initial feedback to the physician and mentor at the conclusion of the visit. The assessor submits a formal report to CAPP, following a standard template, which is shared with the physician, mentor, and sponsor. The various assessors are nominated by the DHAs and approved by the CPSNS. CAPP assigns assessors, both to distribute the workload and to avoid assessments within their own DHA.

At 10 months, to assess the physician's performance, we conduct a multisource feedback using standardized questionnaires that were specifically developed by assessment bodies in two other Canadian provinces for IMGs holding defined licenses.6 CAPP receives questionnaires directly from 25 randomly chosen patients, eight medical colleagues, and eight other coworkers, who may be either other health care professionals such as nurses, pharmacists, social workers, physiotherapists, etc., or office, clerical, or administrative staff in the practice, local hospital, or community. The CAPP physician supplies the program with a list of references, from which the last 16 are chosen. A fourth questionnaire, a self-assessment, is obtained from the CAPP physician. The questionnaires are scored and analyzed independently of CAPP by research colleagues who originally developed the questionnaires at the University of Calgary, and reports are provided to the physician, mentor, sponsor, and CAPP. The number of questionnaires given to each group of people was determined in pilot projects to balance the feasibility of obtaining a reasonable sample size with the need for producing valid data while maintaining the confidentiality of all respondents.

At the conclusion of Part B, the physician's performance, as evidenced by a summary of the mentor's progress reports, the external assessor's report, the multisource feedback report, CME activity, and the mentor's summary statement, is reviewed by the CPSNS Credentials Committee. This committee grants continuations of defined licensure, specifies any conditions attached to licensure, mandates any further follow-ups, and decides whether the formal mentorship needs to continue. When the mentorship period is over, the physician moves on to Part C.

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Part C: Obtaining full licensure and certification

During Part C, the CAPP physician, as a defined licensee, must continue to have a sponsor approved by the CPSNS; this sponsor, the same sponsor as before, provides CPSNS with semiannual reports during the first year of practice and an annual report thereafter. During Part C, the physician must obtain both the Licentiate of the Medical Council of Canada (LMCC) and certification by the College of Family Physicians of Canada. Currently, physicians with a defined license for family practice have a maximum of four years to complete the requirements for a full license. An IMG physician can earn LMCC licensure by successfully completing both parts of the council's qualifying examinations. A defined licensee can obtain certification by the College of Family Physicians of Canada through the practice-eligible route (in contrast to completion of a formal family medicine residency), which requires five years of active family practice, two of which must be in Canada. Thus, many CAPP physicians can attempt the certification examinations in the third year of their practice in Nova Scotia (having had at least three years of family practice abroad) and, if unsuccessful, again in their fourth year. If they fail to meet this deadline, their defined license may not be renewed. (No CAPP physician has reached this stage of the program; therefore, none has failed to receive full licensure, but one could anticipate a strong community reaction should a popular and “successful ” physician be denied continuation of defined licensure.)

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Program Funding

Because start-up funding from provincial and federal governments was not forthcoming, the council of the CPSNS committed funds as a loan, anticipating that the program would become self-sufficient within 24 months. Candidates pay an examination fee for the Part A assessment. Some candidates have expressed concern about the amount of the fee charged: 5,500 Canadian dollars; however, the assessment must be conducted on a cost-recovery basis. The Nova Scotia DOH has provided funding in support of Part B, including mentor stipends and partial support for the mentorship coordinator, CME costs, and costs for the external assessment and multisource feedback. CAPP subsequently received a one-time Health Canada grant to assist with implementation of the program. Since then, Health Canada funding has been received for the orientation program and a planned mentors’ focus group and workshop. In 2007, the DOH provided one year of funding to support the infrastructure of the program.

The DOH issues formal contracts both to the CAPP physician and to the mentor. The CAPP physician signs a four-year contract with the DOH and the DHA. The first year's compensation is guaranteed with subsequent years’ pay continuing as during the first year, changing to fee-for-service, or becoming a blend of both. Contract completion results in a bonus to the physician.

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Program Outcomes

The 2005, 2006, and 2007 cohorts

CAPP was established in mid-2004 and offered its first assessment in June 2005. The outcomes of the first four cohorts are outlined in Table 1. Because of initial demand, two assessments were conducted in 2005; subsequently, one assessment per year has been offered.

Table 1

Table 1

The 148 applicants from 2005, 2006, and 2007 received their medical education in 26 countries—the majority in South Asia (50%), the Middle East (25%), and Eastern Europe and Russia (10%). Virtually all of these CAPP physicians graduated between 1970 and 2007—43% between 1981 and 1990. Fifty-three percent of these 148 applicants are female. Although the majority of candidates resided in Ontario (105), there have been candidates who lived in Nova Scotia (25), British Columbia (6), Quebec (4), Alberta (3), Manitoba (2), Newfoundland and Labrador (2), and New Brunswick (1).

Even though CAPP is a Nova Scotia program, large numbers of candidates have lived in Ontario because the greatest concentration of IMGs in Canada is in southern Ontario near the greater Toronto area. Candidates who are granted a defined license relocate to Nova Scotia to practice and live there. Nova Scotia, with a population of one million, has about 1,000 family physicians. There is an insufficient number of IMGs living in Nova Scotia to sustain the CAPP program and provide the numbers needed to care adequately for the citizens of that province. Twenty-seven CAPP physicians from these first four assessments are now in family practice in Nova Scotia. Twenty-five are practicing in small and medium-sized communities.

The reduction in the number of candidates (see Table 1) has been significant and may be associated with at least three factors: the relatively low success rate in obtaining licensure (see reason below), which discourages potential applicants; the increase in residency positions and expanded IMG programs in Canada; and, possibly, fewer eligible IMGs in Canada than previously estimated. There is no definitive, accurate count of the number of IMGs in Canada who are seeking to practice in Canada. Media reports may have overestimated the numbers seeking licensure and practice opportunities.

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Future funding

The June 2007 assessment had 20 candidates, which is near the lower limit necessary to sustain the program. There have been discussions to determine whether provincial funding will be cost-effective to continue CAPP. From previous experiences, five to seven new CAPP physicians can be anticipated from a cohort of 20 candidates. The CPSNS and its credentials committee set a relatively high standard for granting licensure because candidates need to be practice ready and to demonstrate their ability to start practice immediately without any Canadian residency training. The cost of sustaining CAPP with this output could probably be justified when compared with the costs of providing complete family medicine residencies for a comparable number of (five to seven) IMGs; however, the success rate for any cohort of candidates is not predetermined and can be quite variable. Once a decision is made to offer the initial assessment (Part A), there is an implied commitment to provide the 12-month (Part B) mentorship component, so any funding decisions need to be made only after a great deal of consideration and planning.

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Changes to CAPP

Resources for CAPP candidates and physicians.

At the time of the first assessment (June 2005), a job information fair was organized by the DHAs, DOH, and Doctors Nova Scotia (the provincial medical society). The fair provided candidates an opportunity to discuss potential practice sites with DHA representatives and contract arrangements with the DOH. Although well attended and positively received by participants, the job fair was not repeated in its original format, because the number of successful candidates from the first cohort was relatively small, and the fair organizers thought their resources could be better focused on those who were successful and deemed eligible for licensure. A much reduced version (sponsored and organized primarily by the DOH) was held in December 2005, and none has been held since because eligible CAPP physicians began to focus more on practice opportunities and site visits. Early on, in 2004, CAPP established a Web site ( to provide information, examples of examination questions, an orientation video of a CAPP OSCE, suggested study resources, and current information about previous assessments.

In addition, a five-day orientation program was provided to the third cohort (2006) of CAPP physicians after they had earned eligibility for defined licensure but immediately preceding their site visits to selected communities. Presenters of each three-hour session covered the following topics: orientation to the Nova Scotia Health Care System, cultural diversity, patient-centered care/collaborative practice, ethical and legal issues of practice, prescribing and narcotic prescribing in Nova Scotia, and use of the Electronic Bookshelf. The orientation also included clinical instruction and experience with female breast and genital examinations as well as male genital examinations. Finally, the session covered an overview of the CAPP physician contract, site visits, and the mentorship component of Part B. Feedback from this cohort, after having been in practice in Nova Scotia for six months, indicated the orientation topics to be relevant to and very helpful in their practice. A similar orientation program was organized for the 2007 cohort.

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English competency.

IMGs contemplating a CAPP assessment are encouraged to have their English language skills assessed and strengthened as necessary before attempting the assessment. CAPP administration believes that the Part A OSCE, through which both physician examiners and standardized patients assess English proficiency for nearly three hours, is a reliable and relevant test of CAPP candidates’ English proficiency. In the first two OSCEs, physician examiners and standardized patients performed identical, but independent assessments of candidates’ communication skills. Analysis revealed a high correlation between the two assessments. To provide examiners with more time to assess candidates’ clinical-reasoning and decision-making skills, physician examiners now provide only a global assessment of communication skills and spoken English (vocabulary, organization, rate of speaking, accent, use of jargon/idiomatic expressions). The correlation between the two groups of assessors with respect to global assessments of communication skills remains high.

Few of the IMGs assessed demonstrated difficulties with English proficiency significant enough to impair their communication with patients. Those few who did were deemed ineligible for licensure. Several of the successful candidates were advised to improve their English proficiency during Part B, and the mentors’ reports, external assessments, and multisource feedback monitored progress in this regard. All these physicians demonstrated improvement during the year.

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Clinical skills.

The 2005 OSCE was adapted for 2006 to incorporate enhanced assessment of clinical-reasoning and decision-making skills, using a key features approach.7 Examiners at 9 of the 14 (reduced from 15) stations use structured questions to probe for a differential diagnosis, the most likely diagnosis, the case features leading to those selections, initial key management steps, and the rationale for selecting these steps. To provide additional time for these new skills assessments, the OSCE stations were lengthened from 10 to 12 minutes.

A content validity study of the clinical scenarios used on the first two therapeutic examinations, using 23 family physicians in Nova Scotia, found nearly all test items to be relevant to family practice in Nova Scotia.

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Improved incorporation of CME.

It became apparent with the first cohort that the CME plan was not particularly well incorporated into CAPP physicians’ practices, especially with respect to the involvement of the mentors. Now, CAPP physicians teleconference with their mentors, the CME coordinator, and the mentorship coordinator eight weeks into their practice to discuss the CME plan and possible modifications in relation to early experiences in their practice. This approach seems to have improved the engagement of the mentor in the CME process. A second teleconference is held shortly after the external assessor's visit to review the CME plan developed by the physician and mentor in response to the feedback and recommendations identified in the external assessment report. Another strategy meant to increase CME incorporation is the requirement that during month 12, the physician is required to submit a summary of CME activities to be included in the documentation considered by the CPSNS Credentials Committee.

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Program research and evaluation.

An active program of CAPP research and program evaluation is ongoing, using mostly qualitative methods, including surveys of stakeholders, mentors, and physicians; integration of IMGs into communities; usefulness of assessment of spoken English; assessment of clinical reasoning and decision making in the OSCE, using the key features approach; and potential links of external assessment and multisource feedback to the initial assessment.

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Assessing specialists.

There has been significant discussion about using CAPP to assess IMG specialists. Plans are underway, contingent on DOH funding, to provide assessment in collaboration with Dalhousie Postgraduate Medical Education for selected major specialties (e.g., anesthesia, internal medicine, psychiatry, general surgery) needed for medium-sized communities. The concept of context-specific practice and assessment is in development. The DHA will identify the scope of specialty practice required for an identified community, compatible with available resources. The context-specific assessment, lasting three to six months, conducted under the direction of the relevant Dalhousie residency program director in a teaching hospital, will be based on the identified context of practice. After a successful assessment, the IMG specialist will be deemed eligible for practice in the identified community within the scope of practice. The mentor will be a certified specialist within the DHA, with, at a minimum, a similar scope of practice to the IMG specialist. Enhancement of the practice context will depend on the availability of community resources and the acquisition of new knowledge and skills through CME by the IMG specialist. This approach—that is, the CAPP model of rigorous assessment, a mentor, CME, and periodic assessments—will be used for practice-ready IMG specialists.

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The value of the mentorship.

Although the initial focus and efforts of CAPP were directed at establishing a credible initial assessment (Part A), it has become apparent that Part B, especially with respect to the mentorship component, along with the on-site assessment, multisource feedback, and the emphasis on an individualized CME plan, is the essential and defining element of CAPP. It is also clear from comments of mentors and CAPP physicians that Part B, especially the mentorship, is very important to the integration of CAPP physicians into their medical and broader communities. In one arrangement that worked particularly well, three physicians were located in one clinic with a single mentor who spent a significant amount of her time mentoring them. Mentors can opt (as a term of their contract) to discontinue their participation at any time. Without a mentor, a CAPP physician is not licensable. Therefore, it is most important that mentors’ concerns and problems be addressed promptly, to avoid escalation and mentor withdrawal. One mentor was replaced on an interim basis because of illness, and another mentor had significant other commitments, which was a factor in reassigning his CAPP physician to another mentor and practice in an adjacent community. Also important is the mentor coordinator's qualities; in particular, our current mentorship coordinator has been a significant factor in the successful implementation of the mentorship component with her ready availability to both mentors and CAPP physicians in order to address problems.

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CAPP and the wider community.

CAPP has been considered a success by the licensing authority, the provincial DOH and DHAs, and the local IMG community. CPSNS and its credentials committee have been very satisfied with the rigor of the initial and ongoing assessments and the comprehensive nature of the CAPP reports. The DOH and DHAs are pleased with the cost-effectiveness of placing CAPP physicians into communities chronically short of physicians. The IMG community, especially in Nova Scotia, has welcomed the opportunity to access an assessment without the necessity of additional residency training, although some IMGs have been critical of the assessment cost and the relatively low success rate. Still, the program has permitted both the assessment of IMGs and their integration into family practice in communities, many of which have been underserved by physicians for years. For example, the community of Yarmouth has been historically short of family physicians, but now three of the 2005 and two of the 2007 CAPP physicians have located and set up practice there. In the smaller community of Weymouth, there had been a solo family physician for six years, but now a CAPP physician has established practice there, resulting in improved access to care and relief for the established physician.

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Summing up.

The CAPP physicians, with few exceptions, have found the mentorship year to be a valuable and rewarding experience. Candidates consider the examinations to be a rigorous but fair assessment of their competence. Many in the broader education, IMG, and licensing authority communities view CAPP as a comprehensive program incorporating several innovative features, especially the mentorship, CME, and on-site and multisource assessments. Because of its comprehensive nature, ongoing funding to support such a program may be an issue, especially if the number of candidates is at the margin of cost-effectiveness. Therefore, if Canada should move to a nationally administered IMG assessment, the licensing authority may wish to use only Part B, in whole or in part, to complement defined licensure for IMGs. With the continuing dependence on IMGs to meet physician workforce shortfalls, especially in smaller and rural communities, CAPP has developed and implemented a model that is proving to be effective in addressing medical care needs while maintaining an appropriate standard of physician performance.

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The following have contributed significantly to the development and implementation of the Clinician Assessment for Practice Program: Dr. Cameron Little, Gwen MacPherson, Sandra Taylor, Patricia Saunders, and Amanda Mombourquette of the College of Physicians and Surgeons of Nova Scotia; Bruce Holmes, Alexa Fotheringham, and Linda Mosher of the Learning Resource Centre, Faculty of Medicine, Dalhousie University; Dr. Mary-Lynn Watson and Dr. Douglas Sinclair, Continuing Medical Education, Dalhousie University; Dr. Kevin Bourke, chief examiner, CAPP; and Dr. Jean Gray, Dr. John Ruedy, and Dr. Brian Hennen, Therapeutics Examination consultants.

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