Canada is an outlier in requiring physiotherapists to pass clinical licensing exams after graduating from their university programs, according to a new research paper that is now calling for a re-evaluation of the usefulness of the competency examination.
The issue is even more evident with in-person exams currently on hold because of the pandemic, resulting in a backlog of more than 2,000 physiotherapy grads unable to take post-degree clinical licensure exams to prove their competency.
“We examined 17 countries’ licensing standards and only Canada (excluding Quebec) mandates clinical exams as a registration requirement for graduates,” said professor Alison Rushton, director of the Western’s Faculty of Health Sciences school of physical therapy.
Nor is there compelling evidence that the extra step actually verifies competence. “Our systematic review identified no studies evaluating examination for licensure, and variations in testing methodologies and adjudication,” she said.
In Canada, physiotherapists must first meet high academic and clinical standards to graduate from accredited university programs; they must then also provide proof of competency by passing written and clinical exams administered by the Canadian Alliance of Physiotherapy Regulators.
The evaluation tool used for the clinical component is an objective structured clinical examination (OSCE). Candidates rotate through 16 clinical scenario-based stations and interact with standardized patients; independent assessors grade candidates’ skills and judgment.
“If it had clear value that it has benefit in licensing physiotherapists and protecting the public, it would be acceptable,” Rushton said. “So, in our research, we asked the question, “Is it doing what it sets out to do?” and conducted a study to ensure that we had robust data to drive an evidence-based analysis.”
Researchers assessed the exam’s measurement properties—specifically, is it reliable and valid?
Five of the six authors of the paper, published in the journal Plos One, are connected to Western’s school of physical therapy, including lead authors Pavlos Bobos and Western Canada Research Chair Joy MacDermid.
The paper found that simulations and standardized-patient assessments are difficult to measure against a real-world setting, and there’s variation in how the OSCEs are administered.
Where some other countries apply the OSCE, it is most often used as an evaluation tool within an undergraduate physiotherapy program.
Licensed Canadian physiotherapists must have a master’s-level professional degree and a bachelor’s degree in a health-related field. They must also have more than 1,025 hours of supervised clinical training before graduating.
Western offers physiotherapy degrees at the master’s and doctoral levels.
“We understand that the exam is currently legislated, and changing legislation is a long process—but we need to adapt. We’re really trying to open up the conversation about whether there are better ways of doing this, better ways of assessing competency based on scientific evidence,” Rushton said.
Obstacles to practice
The Canadian Alliance of Physiotherapy Regulators responded to limitations imposed by the pandemic by launching virtual clinical exams—but quickly ran into issues with the virtual platform. They plan to launch a revamped platform in September.
In the meantime, three cohorts of physiotherapy graduates, including internationally trained physiotherapists—1,000 candidates from Ontario and a total of 2,065 across Canada—have been affected, with no access to the clinical exam.
Instead, they must work under provisional license, under the supervision of a licensed physiotherapist.
The five Ontario universities that offer physiotherapy programs have together already pledged in a statement to work collaboratively with all partners to “facilitate safe entry [into the profession] to candidates as soon as possible.”
Ironically, Rushton said, the main aim of it all—patient protection and the public good—may be compromised, not because of less-than-competent physiotherapists but because the licensing issue has become an obstacle to meeting patient demand.
“When we’ve got people who can’t be fully registered, it has longer-term ramifications in addition to many immediate personal ramifications,” she said.
The office of the Ontario Fairness Commissioner noted in a June 2021 letter to the College of Physiotherapists of Ontario (the profession’s licensing body in the province) that applicants have endured hardships “arising out of the cancellation of examinations, coupled with a regulatory framework that is viewed as inflexible.”
The commissioner lauded the recent formation of a working group of the College of Physiotherapists to modernize entry-to-practice processes but said the College “has not exhibited a sense of urgency” in working to help candidates seeking registration in a timely way.
“It is not acceptable, for example, that a registration process stops applicants in their tracks during a pandemic,” that letter continued, recommending that the regulator “proactively take whatever steps it can to relieve the burden on current applicants to the system.”