Opinion

Who is monitoring the gatekeepers? The Royal College an impenetrable fortress

Yes, I failed the Specialty Examination of the Royal College of Physicians and Surgeons of Canada (Royal College). This is a fact. But that does not preclude me from expressing what I consider to be wrong.

You may feel this is the story of someone that cannot tolerate failing, but I can assure you that this is not the case. Based on discussions with many colleagues in different specialties, it is likely that my story is shared by others, either because they faced the same situation or because their own reflections led to similar perceptions of the process.

My score at the written examination was between 65 and 69.9 per cent with a pass rate at 70 per cent, leaving me between one and seven questions short of passing. However, since I had identified a factually inaccurate question, I decided to request a Formal Review. The Summary of Performance given to candidates does not detail which questions were failed, meaning I had a legitimate concern that what was an accurate answer was improperly marked and led to my failure. In addition, in my request for the Formal Review, I highlighted concerns that if one question was inaccurate, others may have been as well. I was indeed surprised when sitting for the examination that there were some inadequacies in the examination questions list. Despite providing evidence, I was not granted a Formal Review.

I had identified a factually inaccurate question.

As I gathered information regarding the processes in place at the Royal College, I came to the conclusion that the processes do not follow the standard that the college imposes on other institutions. The opacity of the examination process, the lack of transparency and the duty to fairness must be addressed.

Examination process

The examination process and appeal do not permit anyone to review the content of the examination as it is deemed “confidential to the Royal College and not shared with candidates.” There is therefore no possibility for the candidates to check the accuracy of the expected answers, not even for the sake of understanding where they failed.

The Royal College insists the questions are designed by “recognized content experts” and that a committee selects the questions deemed suitable for the examination. When a request for appeal is made, there is limited chance of success since candidates do not have access to anything tangible. Moreover, the Royal College does not accept appeal requests for what it considers to be an “alleged error in content.” Despite providing detailed information to the Royal College to support my claim as evidence-based, this did not suffice.

The Royal College also indicated that psychometric analyses help identify errors. I do not share that opinion since psychometric analyses do not have the possibility to identify inaccuracies, but rather only a pattern of response from the candidates. During a review course prior to the examination, a participant asked about the question that I reported as factually inaccurate (in a slightly altered stem but with the same factually inaccurate concept). If the psychometric analyses had performed as adequately as the Royal College argues, this question would have been removed from my examination question list.

Lack of transparency

Passing or failing the specialty examination has tremendous professional impact on candidates. Thus, the Royal College has a responsibility to engage in a trustworthy relationship with candidates who aim to become fellows of this institution. Unfortunately, I do not believe that such a relationship exists.

No clear and detailed feedback is provided to the candidates to allow them to improve.

The Royal College examination process is not transparent, which is inconsistent with the rules it makes when accrediting the Residency Program and external Continuing Professional Development (CPD) programs. In terms of the Residency Program, it stipulates that “the central policies and processes that address […], assessment, […], and appeals are regularly reviewed, transparent, and effectively applied.” Unfortunately, there is no similar call for transparency in its own examination and appeal processes. For the CPD programs developed by other agencies, the college states that “the self-assessment program must provide detailed feedback to participants on their performance to enable the identification of any areas requiring improvement through the development of a future learning plan. Providing specific feedback on which answers were correct and incorrect with references […].” But in the college’s case, it does not provide clear and detailed feedback to its candidates to allow them to improve. It only provides a Summary of Performance that details a percentage by subcategories in the Specialty. Since some of the questions were quite inadequate to test the readiness to practice in my opinion, I do not really see how this summary can be of any particular use for future improvement.

Duty to fairness

As I was researching the Royal College, I was surprised that I could not identify a monitoring entity that oversees the activities of the Royal College and ensures that it follows ethical and legal practices. However, I did come across a landmark case in administrative law that provides guidance to ensure duty to fairness in the decision-making process of administrations. In my opinion, the Royal College, in the context of the examination process, does not follow any of the five criteria established in Baker v. Canada (1999).

A positive decision made by the Royal College gives a candidate the ability to work independently. Thus, the decision-making process resembles an administrative judicial process. Therefore, the principles of procedural protections should be in place. In other words, the Royal College should not have the power to restrict someone’s practice without giving the candidate a fair appeal process. The fact that it denied my claim without any explanation is not in keeping with these principles. Moreover, not being given access to any evidence to support an appeal claim does not meet the principles detailed in Baker v. Canada (1999).

A fair and transparent process needs to be in place.

When analyzing the Royal College’s processes in the light of this landmark case, it is important to consider the impact of passing the examination. Remaining a non-FRCP/SC practitioner not only has a significant impact on someone’s professional, but also on a personal level. Notably, having to spend hours studying again for this examination without any clarity as to how to study differently is not a trivial issue.

Conclusion

In my opinion, it is important that an agency such as the Royal College act as a gatekeeper of Specialty Medicine in Canada. It permits us to have high quality and homogeneous training and practice across the country. However, a fair and transparent process needs to be in place.

I am not going to debate the utility of the written examination; others already have done it. But I can doubt the accuracy of some questions (beside the one that was factually inaccurate) since a unique answer is not always possible. The Royal College has control over information that it will share, leaving candidates with little to contest. In an answer to one of my communications, the college expressed the fact that in its view, its processes are fair. Unfortunately, I continue to question that claim given how the Royal College governs its processes.

In my case, I know that I do not have any choice other than registering for the examination again. I just hope that in the meantime, the concerns I raised are heard and that the processes are improved. I also hope that presenting my case will help those who may, like me, have felt defeated; maybe some will feel that they can also speak up.

I am sharing a longer version of this article with the Minister of Health, the Minister of Mental Health and Addictions and other Parliamentarians. You can read that version here. Publicly voicing concerns may not be sufficient to allow for a change in process; engaging the decision-makers who have the power to impose a change may be necessary.

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4 Comments
  • My initial is M says:

    I thank you for sharing. I can’t get over it and I can’t force myself to retake exam again.

  • Dr. Rob Murray says:

    There has been regulatory capture of medicine by industry in Canada. It is not surprising that PHAC is headed by infectious disease doctors and not those from public health. Guidelines are meant to help patients and assist physicians. Canadian courts have agreed that guidelines are just that, guidelines and are not meant to be mandates by private specialty groups such as AMMI [Canada] and the IDSA to whom AMMI members owe their allegiance and take their direction. No matter what your opinion Lyme and tick-borne disease [TBD] patients are clearly suffering from the debilitating symptoms of long-Lyme or complex disseminated Lyme disease.
    100% of Canadian doctors treated beyond what is allowed by the rigid IDSA guidelines have been investigated compared to 20% of the general medical practitioners. Many physicians have been harassed, removed from practice or forced to sign silencing agreements. Patients are caught in the middle between ILADS and IDSA/ AMMI doctors and are losing their health, jobs, homes and lives. We hope that the interest in long-COVID will give practitioners pause to reconsider what they have long understood to be ‘fake’ diseases such as fibromyalgia, ME/CFS etc. “Listen to your patient, listen to your patient – he is giving you the diagnosis.” -Osler

    The long-term disability insurance industry doesn’t want to underwrite the cost of chronic disease. Industry has found that if it can control medical guidelines such as those for Lyme, it can control medicine. The May 2016 Conference to Develop a Federal Framework on Lyme Disease was mandated by the Act to develop a made-in-Canada set of Lyme guidelines. The Conference itself was balanced but that is when the public health doctor in charge of the Conference was replaced by infectious disease physicians. A final Report was produced, without transparency or collaboration, that only mentioned that patients were heard. The status-quo report was designed to convince politicians that they were in good hands. Nothing has been done since to help patients except for a bit more surveillance to help patients.

    PHAC under the watchful eye of Dr. Howard Njoo has prioritized the preservation of the antibiotic supply over returning Canadians to health. Infectious disease doctors have abandoned their colleagues in family medicine who have to live with their patients.

    The Royal Colleges are willing industry partners. Lyme is a clinical disease but the Royal college has told us they couldn’t possibly allow their physicians to diagnose Lyme clinically with all those changing symptoms. Physicians have not been told that the present tests used here miss at least one third of those that truly do have the disease. It’s the test that got us into all this trouble and it must be abandoned.

  • Rosemary Pawliuk says:

    Thank you for the incredible amount of work you did on this important issue which impacts not only those seeking certification but the public interest and the integrity of our health care institutions.

    Society for Canadians who Studied Medicine Abroad has been communicating with the RCPSC about these same issues which also negatively impact Canadians who trained abroad and want to return home to practice. Most never do. I was told by Health Match BC several years ago that their best estimate is that only 5% of those who train in the USA return home. Health Canada estimated between 5% and 20%. Although there are various factors which influence a Canadian’s return home, a significant factor is the RCPSC certification examinations.

    We have passed on the feedback we received from our members about the quality of questions, the reporting of results, the lack of transparency, the lack of feedback, the procedural unfairness, and the fact that we have viewed some exams where on the scant reporting which was expressed in “placement within standard deviation” it seemed impossible that the person could have failed but did. Appeals we have seen provide little more than a denial.

    In addition, we expressed concern over the fact that some Canadian physicians who trained in the USA passed the American Board exams in the 90th percentile and higher and yet failed the RCPSC certification examinations. Certainly, if the RCPSC were testing fundamental medical knowledge for safe practice, this fact should be troubling. The RCPSC is not troubled. The RCPSC suggested that those trained in Canada may simply be substantially better trained than in the USA. Really? Is it possible there might be other factors that might come into play and need to be examined critically?

    Another matter we took up with the RCPSC is the fact that despite an express rule against replicating exam questions and using past exams to study, those training in Canada are provided with and study from past exams. They are also schooled in the importance of recognizing the courtesy and value of the replication of these exams and ensuring that the tradition continues for future candidates. We advised the RCPSC that we have a few members who trained in the USA who advised us that but for being able to get these exams from their friends who are training in Canada, they were certain that they would not have been able to pass the exams.

    The RCPSC acknowledged that it was aware that those studying in Canada– despite the prohibition by the RCPSC– had and used these exams to study. However, when we stated that fairness required that the old exams be made available to those studying outside of Canada as well, the RCPSC refused. They responded that it was an imperfect system but that the “legitimacy” of the process prevented the release of past exams. Really, even though the vast majority of the candidates who wrote the certification exams, i.e., those training in Canada had these exams studied from past exams? The RCPSC stated that only about 30% of old questions are re-used. The rest are new. How could this possibly be reassuring considering that one question can make the difference between pass and fail?

    A fair-minded, objective person would recognize that access to past exams for most but not all candidates is a corruption of the system and requires remediation by making past exams available to all, at least until an alternate system of leveling the playing field can be developed. The RCPSC does not see it this way.

    Even in the absence of the unfairness of a small group of candidates being denied access to past exams, one must question not only the rationale for not permitting past examinations as study tools, but why certification exams are not open book. Is the purpose of these examinations really intended to test competence for practice or are they an initiation ritual? How many physicians who are certified, licensed, and in practice would pass these exams today? If the answer is anything less than all or almost all, then the examinations are clearly being used for purposes other than establishing competence in the fundamentals necessary for public safety.

    Where is the oversight of this powerful gatekeeper?

    Rosemary Pawliuk, president of Society for Canadians Studying Medicine Abroad

  • Linda Latcham says:

    I applaud you for speaking up! In such a politically entrenched system, speaking up has many consequences for doctors and medical staff and speaks very loudly about how ongoing learning and updated education can be stifled at the expense of the health of the taxpayers paying for this system.

    I believe that to revamp our crumbling healthcare system we must start with the education system for doctors and all other medical support positions.
    It is the taxpayers of the province that pay these doctors and the knowledge base they have(or don’t have) and the updating of that knowledge are critical to the patient’s(taxpayers) health and well-being.

    The medical industry has been allowed to be run by elitist doctors that are not accountable to the people paying their wages. In most cases the contact information for any of the these six figure paid elitists is not available to the taxpayers that pay them.

    The medical industry has become reliant on pharmaceutical drugs being utilized that have serious and in many cases deadly side effects and in many cases are only symptomatic treatment for many diseases. The pharmaceutical companies are “for profit” companies with shareholders that require them to make money.

    In many cases the pier reviewed science can show evidence of many alternative options that have been used for years, however, the hierarchy of OUR medical system clearly does not keep up with the science or insist that the medical education system updates all medical staff at least annually.

    Take a look at the science at the National Institute of Health in the United States(U.S. government research facility), as just one of many learned institutions.You will find a great deal of science that discounts current pharmaceutical drugs used or alternative medicine that has better outcomes than commonly prescribed medicines.

    This intentional ignorance has DONE HARM to many of the taxpayers that pay these entitled leaders of OUR medical system.

    I was diagnosed in 2018 with Myalgic Encephalomyelitis(ME/CFS) formerly called Chronic Fatigue Syndrome. It was a major life altering health change that rendered me mostly home bound. My response to this diagnosis was to learn as much as I could and find whatever I could find to improve this “severe and permanent” disease.
    What I came to realize, after years of scientific study, is that we have allowed the hierarchy of our medical systems to pick and choose what doctors will or will not consider a disease or disorder, in spite of the science. Though the World Health Organization, and many leading healthcare educational universities recognize this disease, and some doctors have put together a Canadian Diagnostic criteria for this disease, there remains an “attitude” amounts to many frontline practitioners and specialists that this is not a recognized disease.
    The immense damage this does to the patient and their families and there life extends to their income and their daily life.

    The power held by doctors, without adequate scrutiny, has created a dangerous and political system that we as taxpayers are allowing to continue.

    ALL medical decision making processes in our healthcare, must have the evenly weighted voice of the taxpayers paying the wages of these doctors and medical staff.

    There can no longer be hierarchy in our medical system that hide their contact information in favour of individuals political or monetary motivations.

    After all my research I was able(through a worldwide ME/CFS group) to find alternative medicine that “did no harm” and improved my quality of life, however, I cannot talk about that to my doctor or most doctors, because they are not only not interested in any remedies that are alternative, but often times they completely discount even looking at the science.

    I realized, as did many of the millions worldwide with this disease, that at the heart of this medical industry ignorance, is an education system and hierarchy in medicine that controls(without transparency) and maintains a system of finite learning in an industry with evolving science.

    I then decided to contact the Royal College on this matter to address the learning that was choosing to “disregard” my disease and this is what I learned(see below the E-mail sent and the much later(after two e-mails) response. Subsequent to the the reply,

    I received no response from any “internal colleagues” that effect curriculum.

    I also had attached scientific links to reputable healthcare organizations and facilities that was not commented on.

    Hi:

    Well, I am not sure if the Royal College of Physicians and Surgeons is taxpayer funded?

    This is the third E-mail sent since September/2021(other two remain unanswered).

    With this E-mail, I will ask that the college review and use the attached science from the National Library of Medicine and numerous other scientific data options and include this data in all future curriculum for all medical staff trained, and also include this scientific data to all active physicians in Canada.

    I will be following up to insure this happens. It is time for the Canadian Medical industry to stop the extensive harm done to over 800,000 Canadians with this devastating disease, many of which are living in poverty, due to physician neglect.

    If you are interested in the actual science, I would be happy to send the links to the science I have accumulated in the last 5 years on this serious multi system disease; including the links to the World Health Organization, the CDC, John Hopkins, Harvard etc, etc. etc.

    Regards
    Linda Latcham

    Dear Linda Latcham,

    Thank you for your email, and our sincerest apologies for the delay in getting back to you about this issue. Your first email must have been missed by accident, and for that we do apologize.

    Unfortunately, the concerns you have raised are outside of the scope of accreditation and may not fall under the purview the Royal College. While there are aspects of the postgraduate curriculum that our organization is involved in, it sounds like your concerns may be broader than that.

    We will pass on your email to some of our colleagues internally who are more involved in setting curriculum at the specialty level, in case they can provide some additional information, but kindly suggest that you also explore other avenues to help address your concerns.

    Kind regards,

    Educational Standards Unit
    Unité des normes éducatives
    T 613 730 8177 T 1 800 668 3740

    Royal College of Physicians and Surgeons of Canada
    774 Echo Drive, Ottawa, ON, Canada K1S 5N8
    Collège royal des médecins et chirurgiens du Canada
    774, promenade Echo, Ottawa (ON) Canada K1S 5N8

    It is time for doctors to band together and speak up en masse and for taxpayers to stop paying for an entitled, hierarchy. Let’s make our healthcare about the science and NOT the politics.

    Regards
    Linda Latcham

Authors

Sébastien Prat

Contributor

Sebastien Prat is a psychiatrist and a medical director in the forensic psychiatry program at St. Joseph’s Healthcare Hamilton and an associate professor in the Department of Psychiatry and Behavioural Sciences at McMaster University. He is currently the President of the Canadian Academy of Psychiatry and the Law, the Secretary-Treasurer of the Canadian Psychiatric Association and the Chair of the Psychiatry and Behavioural Science Section of the American Academy of Forensic Sciences.

prats@mcmaster.ca
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