Physiotherapy Competency Exam (PCE), Why It Must Change (Or Not) To Reflect Current Evidence
By: Nataliya Zlotnikov MSc, HBsc
By: Nataliya Zlotnikov MSc, HBsc
The What, When and Who
On 15 September 2021, Darryl Yardley, physiotherapist, and founder of Mentorship Bootcamp hosted a live webinar, Why the PCE Must Change (Or Not) To Reflect CURRENT Evidence, as part of his PCE Webinar Series.
Much was discussed on this day, and much remains to be discussed.
Take a look at this 45-second video in which Michel Landry expresses his support and discusses what he hopes to achieve in the next hour.
One of the ideas that Maggie, Darryl and Michel arrived at at the end of this webinar was the creation of a GoFundMe campaign in support of the PT Residents and IEPTs who are waiting to be licensed.
The funds will be used to create a national mental health support program and other programs to support the advancement of physiotherapy in Canada.
CAPR will focus on the written exam and getting back to delivering a face-to-face clinical component. The timeline to deliver a clinical component is to be determined.
This marked the 4th cancellation of the PCE Clinical Component since the start of the pandemic.
With so many justified strong emotions in the air, this webinar could have taken many turns.
However, the host and panellists opted for a respectful, progressive, and open discussion around these difficult issues as they sought to find a way forward for our profession.
The webinar primarily focused on finding immediate solutions to support our PT colleagues (both nationally and internationally trained) going through this difficult time, and those slated to graduate in the coming weeks.
What Was Discussed
We understand that many of you were unable to attend the live webinar. We are sorry to have missed you. But we'd like to catch you up on what was discussed.
Below is an outline of the major topics that were discussed in this webinar.
Each point will be expanded upon in the blog below.
- Why Did CAPR Choose to Relaunch Another Virtual Exam Instead of Going Back to In-Person?
- History of Physiotherapy Regulation in Canada
- Are Objective Structured Clinical Examinations (OSCEs) Valid? A Data-Driven Discussion
- Provincial Physiotherapy Licensing and Examination Changes During COVID
- The Case for Quebec
- Next Steps
- Outreach and Support
I. Why Did CAPR Choose to Relaunch Another Virtual Exam Instead of Going Back to In-Person?
Let's start this segment by clarifying that none of us actually know why this decision was made.
That being said, the major hypothesis amongst the attendees is neatly summarized in the sunk-cost fallacy.
Basically, "follow through on an endeavor if we have already invested time, effort or money into it, whether or not the current costs outweigh the benefits" (The Decision Lab, 2021).
Image source: The Decision Lab
II. History of Physiotherapy Regulation in Canada
Self-proclaimed 'old and ugly', physiotherapist and Queen's University Professor, Diana Hopkins-Rosseel, has been in the PT game for quite some time.
Throughout her career she has witnessed the profession go through 3 crises; the current one being the 4th.
"There are ups and downs and controversies in every profession.
Throw in something like COVID and it will bring a lot of the difficulties that might be percolating to the surface."
She kindly took the time to impart upon us a brief lesson on the recent history of physiotherapy regulation in Canada.
We have included some of the information that she shared below, along with some additional historical information not discussed in the webinar for context.
We are nothing if we do not know our history.
Join us for this tale.
any, many years ago...
1895: Roots of physiotherapy in Canada started with a small group of British nurse-masseuses who formed the Society of Trained Masseuses (ISTM) (Miles-Tapping, 1989).
In 1915, The Toronto Society of Trained Masseuses was formed.
The Montreal Society was then formed in 1918.
In 1919 the Montreal Society applied for a Provincial Charter to formally recognize the profession.
On March 24, 1920, The Canadian Association of Massage and Remedial Gymnastics (CAMRG) with the aim of Canada-wide standards of education and practice (Physical Therapy University of Toronto, 2021).
In 1924, Ontario became one of the first provinces to regulate the profession under the Drugless Practitioner’s Act (Ontario Physiotherapy Association, 2020).
The Association (CAMRG) was later renamed the Canadian Physiotherapy Association (CPA) (1935) (Heap, 1995).
Established in 1954, The Ontario the Board of Directors of Physiotherapy was the regulator that predated the current College. The Board and all physiotherapists were appointed by the Minister of Health and the mandate included registration and complaints management. It was the first in Canada for the profession (Dianne Millette, Registrar & CEO at College of Physical Therapists of BC).
In 1991, the Physiotherapy Act launched the creation of the College of Physiotherapists of Ontario. The College oversees the profession, ensuring ethical practice. All physiotherapists providing services in Ontario must register with the College. They must also have completed a master’s degree from a Canadian university (Oriole Physiotherapy & Rehabilitation Center, 2021).
Physiotherapists were now recognized by the provincial government as one of a restricted number of self-governing health care professions (Ontario Physiotherapy Association, 2020).
At the time of these regulatory decisions, many provinces realized that they could not afford to run certifying exams provincially due to the high costs associated with them; national testing was a much more affordable idea.
Out of this need, CAPR was born, however, we must remember that CAPR is
simply 'the hired help.'
CAPR was formed in the early 1990s. Canadian physiotherapy regulators banded together to form the Canadian Alliance of Physiotherapy Regulators.
But we must remember that the true power rests within the ministries of health in the individual provinces. This power then flows down and into the colleges.
III. Are Objective Structured Clinical Examinations (OSCEs) Valid? A Data-Driven Discussion
On 3 August 2021, PLoS One published the following systematic review and meta-analysis (Bobos et al., 2021).
This review found that Canada (excluding Quebec) is the only country out of 17 implementing a clinical competency exam to their home physical therapy graduates for licensure.
The paper concluded that an immediate post-professional OSCE as a requirement for licensure for Canadian program graduates is unnecessary.
We were also quite fortunate to have the first author of this review, Pavlos Bobos, join us for this webinar and share his opinion and some concerns on OSCEs and the current situation:
Pavlos expressed that from a research perspective, it is complex to design a reliable and valid high-stakes exam, especially without prior research.
CAPR has not conducted any research.
He also believes that you cannot use a single time point to test professional competence. It is simply not representative.
"You are not protecting the public, you are not evaluating competence."
Take a look at this 3-minute video from the webinar in which Pavlos Bobos expresses some of his concerns on OSCEs and the current situation from a research perspective:
Pavlos Bobos on OSCEs
To this, Diana Hopkins-Rosseel added that she and a group of colleagues are also conducting a systematic review on the OSCEs.
Their paper is not yet published and therefore cannot be discussed beyond stating the following point. Her groups' research agrees with Bobos' research on many points, however, other points diverge.
Similarly to Pavlos, Diana expressed the following viewpoint:
"Although written examinations are valid and reliable, there really is nothing out there that is valid and reliable to the extent that you could test the deep-down hands-on clinical work that we do."
IV. Provincial Physiotherapy Licensing and Examination Changes During COVID
As mentioned above, the power of licensing seems to lie with each province.
So what have the individual provinces done during COVID?
We had a range of cross-provincial invigilators, physiotherapists, newly licensed physiotherapists, and recent graduates join on and speak on what took place in their province.
Below is a brief summary table (Table 1) of the provinces discussed in the webinar. This is followed by a more detailed explanation from our provincial correspondents.
Note: Quebec is discussed in the subsequent section (Section V), The Case for Quebec.
Unfortunately, due to time constraints and a shortage of correspondents, we did not discuss every province and territory. However, we have included a link to their pertinent colleges or legislations in Table 2.
It is our hope that this cross-provincial information provides us with additional tools for learning, growth, and progress within our profession.
Table 1: Summary Table of Provincial Physiotherapy Licensing and Examination Changes During COVID
Successful Virtual Provincial Exam, Licensure Changes:
Justin Chipperfield, invigilator for the BC virtual exam
With additional comments by Chris Smerdon, Manager, Registration and Quality Assurance at the College of Physical Therapists of British Columbia:
- A virtual exam took place through Zoom.
- 23 examiners and 75 candidates participated.
- The examiners held a few prep meetings and dry runs to ensure smooth results.
- The day of the exam was long but ran smoothly.
- The exam took place through The University of British Columbia (UBC).
- A bylaw change (June 2021) allows for this alternate clinical evaluation by UBC.
- Results were given to examinees within days of taking the exam.
- Both domestic and internationally trained graduates sat the exam.
- Prior to COVID, BC was the sole province in which you could apply for a 15-month interim license prior to sitting the PCE written component (PCE-W).
- However, if you were applying after a failure of the PCE-W registration would not be granted. Furthermore, if your latest result on the PCE-W was a failure, you would be unable to practice and your permit would be cancelled.
- During the pandemic, BC implemented a temporary policy decision made by the Registration Committee (April 2021). This decision required Canadian and/or internationally educated physiotherapists to first pass the PCE-W before applying for the interim registration.
- This policy decision was made in an effort to conserve College resources (the College closely monitors interim permit holders).
- Furthermore, the policy decision allows for an extension of the interim license beyond the usual 15-months as now these permit holders are only waiting for the clinical component.
- Pre-April 2021 interim permit holders who have not yet passed the PCE-W will not be granted extensions beyond the 15-months.
- Post-April 2021 interim permit holders can be granted extensions.
- Reinstatement of licenses: The Registration Committee considered applications in October 2020 and again in summer 2021. Applicants were eligible even with one failure on the clinical examination. Registration for the next available clinical examination is always a requirement. The Committee considered several applications from people who had never been registered anywhere in Canada but had one clinical failure. All those reinstated have enhanced supervision conditions.
Successful Virtual Provincial Exam, No Licensure Changes:
Tia McLean, recent graduate who became fully licensed:
- Eligibility was determined based on date: To sit the Alberta in-person exam, graduates had to be interns in Alberta as of 1 March 2020.
- This excluded many and was very cutthroat.
- The Faculty of Rehabilitative Medicine at the University of Alberta facilitated the exam.
- In her opinion, it went off without a hitch and appeared easy to execute.
- Outdated elements had been removed.
- To the best of her knowledge, there were no legislative changes.
- At this time, they also didn’t plan to do this for any other cohort of graduates; she is not aware whether there was a legislative reason for that.
- Can Physiotherapists licensed through this exam practice in other provinces? Provincial response varied when they looked into this issue. However, lawyers have told Tia that it would be extremely difficult to stop you from practicing in other provinces.
No Provincial Virtual Exam, No Licensure Changes:
Scotty Butcher, BScPT, MSc, PhD, ACSM-RCEP Associate Professor, School of Rehabilitation Science University of Saskatchewan
- Saskatchewan graduates received a single update since the cancellation - they are currently in a 'holding pattern'.
- An announcement regarding the issue was forecasted for the week of 20 Sept 2021.
- No virtual exam has taken place.
- Recommendations from the Physiotherapy Competency Exam SCPT AD HOC Working Group (20 May 2021) suggested that:
Candidates who have successfully graduated from a Canadian fully accredited MPT program no longer be required to sit the PCE-C to be eligible for licensure in Saskatchewan.
- Despite these recommendations, no decisions based on the recommendations are being put into place for the current cohort.
- Local alternative: It appears that Saskatchewan is looking for a short-term solution. They are calling this their 'Plan B' - an alternative exam, termed an 'alternative objective third party assessment method recognized by Council.'
- The Plan B exam just got passed through by-laws to allow for its use in the case of a pandemic.
- This exam is being discussed as a replacement, NOT as an exemption.
- This will be a local exam, however, it will not come into play for this cohort.
- No exam has been established as of yet.
- Graduates are awaiting news from the Saskatchewan College to find out what will take place.
- This applies to Canadian graduates only; it is still being recommended that international graduates participate in the PCE or equivalent exam.
Anna DiMarco, incoming President of the Manitoba Physiotherapy Association
- Languishing in limbo: Currently, there is no plan in place and the College is not answering any of the graduates' questions.
- The sole response graduates have received has been asking them to cease and desist if the tone of a specific email rubs the College the wrong way.
- Currently, there is no plan in place except to wait for CAPR.
- Anna was asked, "Who holds the power to implement legislative changes in your province?" To which she responded that Manitoba has a really great act that is generous in its language and allows them to license their registrants without a clinical exam because they have an exemption clause that actually has been used in the past without any legislative or regulatory change.
- She brought this last point up in their town hall meeting in May. Furthermore, she had a lawyer look at the act. The lawyer agreed with her interpretation of the wording.
- She asked the Council’s lawyer about his thoughts on the wording and he agreed with herself and her lawyer.
- Despite this, the college has been publicly saying that they need legislative changes.
Partial Licensure Changes During COVID
Will Howatt, physiotherapy resident
- On 13th Sept 2021, the College released a statement that grouped all 25 residents into 4 categories based on how long they have been working as PT residents in New Brunswick (i.e. not in one of the other provinces or territories). The 4 categories are outlined below:
- They determined that the 3 candidates who have been working for ≥18 mths are able to apply for full licensure without attempting the PCE clinical exam.
- This includes international graduates and candidates with a previous exam failure.
- The other 22 candidates will be waiting for an in-person CAPR exam.
- There's no word about what will happen if the remaining 22 reach 18 months working in New Brunswick.
- Swiss cheese legislation: Will and a few other graduates have looked at the legislation and it is full of holes.
- The legislation does not state that there are 2 exams, nor does it mention the need for a clinical exam. It only states that the council needs to approve it.
- It also appears that this new licensure exemption will not be accepted everywhere in Canada.
Attempted Virtual Exam, No Licensure Changes
Ontario was not discussed in the webinar due to time constraints, however, we are including pertinent information below:
- CAPR ran virtual Clinical PCE exams on the 8th, 11th, and 13th of September.
- The exams were successful for some graduates but not for others.
- After this 4th cancellation, all virtual exams were cancelled.
- CAPR will once again focus on delivering a face-to-face clinical PCE.
- The timeline to deliver a clinical component is to be determined.
- Physiotherapy Regulatory Colleges were advised to communicate directly with their own candidates regarding licensing.
- CAPR will issue a full refund for the clinical component of the PCE to impacted candidates.
- Data for those candidates who were able to complete the exam without interruption will be shared with regulators to inform licensure decisions.
- Candidates with completed exams should contact their regulator for further information.
The Ontario Physiotherapy Association released this letter that they sent to the College of Physiotherapists of Ontario on September 21, 2021.
Table 2: Additional Provincial Resources
For additional information regarding each province, we invite you to visit the hyperlinked text in the table below if any of the below information is of interest to you:
V. The Case for Quebec
Jalisa den Hartog, recent graduate who became fully licensed:
- In Quebec, they offer an undergraduate degree in physiotherapy. However, in order to be licensed as a physiotherapist, you must also complete your master’s in physiotherapy. Those who complete the undergraduate program in physiotherapy and maintain a certain GPA are automatically allowed into the physiotherapy master's program.
- If you did not do the undergraduate physiotherapy program in Quebec, you can still apply for the physiotherapy master's at McGill, however, you will need to do a qualifying year.
- A “qualifying year” is an extra 2 months added to the 2-year program.
- Jalisa completed her Bachelor’s degree in Kinesiology in Nova Scotia and then applied for the Qualifying Year (Master’s in Physiotherapy) at McGill in Quebec.
- Those who graduate from a Quebec University and have proved they can competently provide physiotherapy services in French are granted a Quebec physiotherapy license through Ordre Professionnel de la Physiothérapie du Québec (OPPQ) without the need to write the PCE exam.
- In Quebec, all the university programs conduct final exams but it is done at the university level.
- The final exams at McGill consist of exams or final projects for each class, the same type of exams that are completed throughout the program after each semester. They may consist of OSCEs as well as written exams/final projects for each class. These exams are different from the PCE and are strictly testing material from each of the courses from that semester.
- To Jalisa’s knowledge there are two ways to prove your French language skills:
- Completed at least 3 years of secondary or post-secondary schooling in French
- Obtain a certificate from the Office Québécois de la langue française (OQLF) by completing a French competency exam. This exam consists of 4 stations that center around communicating in French in the physiotherapy field. A physiotherapy-specific case is presented and exam participants are required to communicate in French through writing, reading, oral and listening.
- Once proven that candidates can communicate in the field in French, then they are granted the OPPQ license. If candidates do not write this exam or fail this language exam, but still have graduated from McGill University, they cannot be granted the OPPQ license. These participants will need to continue attempting the OQLF exam if they want to be licensed in Quebec or they will need to write the PCE exam in order to get licensed in another province.
- Jalisa wrote the written component of the PCE exam and passed. However, because of the situation with CAPR, she also decided she would sign up for the OQLF exam.
- There is no cost to take the OQLF exam.
- Jalisa passed the OQLF exam and thus became licensed through OPPQ. A letter of good standing was then sent from OPPQ to the Nova Scotia College of Physiotherapy. Nova Scotia then granted her a license in Nova Scotia.
- We would like to highlight that she did not need to take the PCE written exam to obtain this license, she wrote this part of the exam before she found out she passed the OQLF exam.
- Jalisa's classmates who graduated with her from McGill University but did not pass/write the OQLF French language exam, are still unlicensed, even though they attended the same University and took the same exams as she did.
VI. Next Steps
We have novel research regarding OSCEs and more research in the works.
So where do we go from here?
The data is important but what's most important at this present moment in time is finding an immediate solution that will help the thousands of colleagues currently stuck and struggling with this situation.
How do we best get them through the system?
How do we help them protect their well-being during this time?
Take a look at this 1-minute video from the webinar in which Darryl discusses progress, advocacy and the dangers of stagnancy:
What Is Next?
VII. Outreach and Support
Although we may not have all the answers, open and open-minded discourse is the first step to finding solutions.
We would love to hear from you and welcome your voices and suggestions.
We have created a GoFundMe account in support of the PT Residents and IEPTs who are waiting to be licensed.
The funds will be used to create a national mental health support program and other programs to support the advancement of physiotherapy in Canada.
Date written: 17 Sept 2021
Last update: 23 Sept 2021