Questions 11 and 15 were updated March 26 for corrections.
1. What happened on March 20th that caused the cancellation of the clinical component of the Physiotherapy Competency Examination (PCE)?
The College of Physiotherapists of Alberta was informed of the cancellation of the examination on the morning of March 20th. Details regarding what exactly occurred remain limited; however, the information we have received to date is that the cancellation was necessary due to severe technical challenges with the platform used to administer the examination. The Canadian Alliance of Physiotherapy Regulators (CAPR) continues to investigate the problem, and the College of Physiotherapists of Alberta anticipates further communication from them in the coming days regarding the source of the problem and potential solutions.
2. Why can’t we toss the clinical exam requirement?
While it may be tempting to simply set aside the clinical component of the PCE, and that certainly is a suggestion that we have heard frequently, the College of Physiotherapists of Alberta cannot opt to do so without careful consideration of the implications.
The requirement that candidates complete a clinical competency examination prior to registration is written into the Physical Therapists Profession Regulation. The only examination approved by Council is the Physiotherapy Competency Examination (PCE) administered by CAPR.
Deviating from use of the CAPR examination, while potentially possible, would need to be done with considerable caution to ensure that a comparable, objective, reliable, and valid assessment process was completed prior to registration.
3. What about the physiotherapist interns who have been unable to practice, and all those COVID patients who need physiotherapy care?
It is correct that some physiotherapist interns have been unable to practice as they await their opportunity to take the clinical component of the PCE. However, it must be remembered that physiotherapist interns in Alberta are eligible to remain on the Provisional Register for two years or until they have experienced two unsuccessful attempts at the clinical component of the examination.
While individuals are granted three attempts at the examination, after two unsuccessful attempts the risk of having the candidate remain in clinical practice outweighs the potential benefit.
In response to COVID-19 and disruptions to the clinical exam, the College of Physiotherapists of Alberta extended all provisional licenses until an exam is available. Therefore, the only candidates in Alberta who are currently unable to work as a physiotherapist intern are those who have been unsuccessful at the examination twice already. Thankfully, very few candidates experience two unsuccessful attempts at either component of the PCE. This means that the vast majority of exam candidates are currently working as physiotherapist interns, providing essential physiotherapy services to Albertans with a range of health concerns and across sectors, including in acute care, ICU, rehabilitation, home care, continuing care, and outpatient orthopedics.
4. Why isn’t the College of Physiotherapists of Alberta advocating on behalf of the PCE candidates?
We are glad that you noticed the difference between the messaging of the College of Physiotherapists of Alberta and that of the Canadian Physiotherapy Association (CPA)!
The College of Physiotherapists of Alberta’s government issued mandate is to serve the public interest. Although the College of Physiotherapists of Alberta is a dual mandate organization, we came to the work of fulfilling some association duties when the Alberta Physiotherapy Association ceased operations and approached the College to take on some of their activities. When the College agreed to do so, it was with the realization that not all association activities would be compatible with our College mandate.
From the start the College has been clear that our primary mandate is to protect the public interest and that we must place public interest ahead of that of the physiotherapy profession.
Physiotherapy regulators from across the country are charged with the same responsibility. The CPA is charged with representing the interests of the profession, including those of PCE candidates.
5. Why hasn’t the College of Physiotherapists of Alberta complied with the CPA’s demands that the clinical exam requirement be set aside?
As already stated, making such a significant change from established registration requirements is not something done lightly, nor should it be. To do so represents a marked deviation from our governing legislation. The CPA can advocate on behalf of PCE candidates, but it has limited influence in changing legislated registration requirements established at the provincial level. Again, these requirements are put in place by provincial governments with the public interest as the ultimate consideration, not the professional’s interest.
6. But isn’t the College of Physiotherapists of Alberta a branch of the CPA and an association?
Although the College of Physiotherapists of Alberta maintains a collaborative working relationship with the CPA, we are not, nor have we ever been, a branch of the CPA. The mandate of the College of Physiotherapists of Alberta is incompatible with that of the CPA and, therefore, we are not able to be a branch.
From the day that we agreed to take on very defined membership activities when the Alberta Physiotherapy Association ceased operations, we have been clear that we are a College first and that our government mandate to serve the public interest will always remain our top priority.
For more information on the College of Physiotherapists of Alberta's history, role, and our primary mandate, listen to College Conversation's Podcast Episode 23.
7. This is the third incident involving the examination process. What is being done to overcome the ongoing challenge?
It is correct that two prior attempts to offer the in-person clinical component of the PCE, in June and November 2020, were cancelled. The cancellation of the March 2021 virtual examination marks the third disruption in the clinical examination process.
Both the June and November 2020 examinations were cancelled due to COVID-19, the public health measures in effect, and the closure of testing centres which precluded offering an in-person clinical examination. Early in the pandemic, CAPR began to investigate the idea of a virtual examination, and with the 2020 cancellations, plans were made to transition to a virtual examination in March 2021.
The College of Physiotherapists of Alberta is currently in discussions with our stakeholders including the College of Physiotherapists of Alberta’s Council, the Ministry of Health, and regulatory legal advisors to review available options to address our legislative requirements for registration given the ongoing issues.
8. CAPR has demonstrated that they are not competent. Why are you still working with them?
People have been throwing around this statement a lot on social media, but it is not based in fact. CAPR has long been a leader in the provision of examination services. Their inability to deliver an in-person examination in the context of COVID-19 and the challenges faced in 2020 is not a reflection of their competence any more than a candidate’s inability to complete the examination in 2020 is a reflection of their competence. Some would refer to the circumstances of 2020 as an “act of God” and in legal terms it’s referred to as a “force majeure", meaning that the circumstances are beyond anyone's control. While it is true that CAPR failed to provide a virtual clinical examination in 2021, the circumstances contributing to the failure are not yet clear.
As a physiotherapy regulatory body in Canada, the College of Physiotherapists of Alberta is a member of the Alliance and will continue to work with our peers in physiotherapy regulation in the interest of assuring the public that all physiotherapists practicing in Canada meet the same minimum standard for competence and that the public interest is assured.
9. Why do we have a clinical exam requirement to begin with? Other professions don’t have a clinical exam.
It is true that not all regulated health professionals are required to complete a clinical examination prior to registration. Each regulated health profession develops licensure requirements consistent with the needs and responsibilities of that profession.
The PCE was developed in the late 1980s and early 1990s to address the following issues:
- The need for a consistent, equitable and fair entry to practice standard for all applicants for registration to practice physiotherapy, including those who did not receive their physiotherapy education in Canada.
- The need to develop a system of checks and balances to address the public interest by having an independent organization, separate from those that specify the physiotherapy entry to practice curriculum or conduct accreditation, verify that the education programs were successful in their efforts to develop competent clinicians.
The clinical component of the PCE has existed since the examination’s inception and reflects the nature of physiotherapists’ daily work. While some forms of knowledge can be tested using a written or multiple-choice examination format, technical skills such as patient handling and treatment techniques, and non-technical skills such as patient education and communication have long been thought to require a clinical examination in order to provide an accurate evaluation of a candidate’s skills and competence.
Physiotherapists have long advocated for their role as primary care providers and have sought to have the same standing in the health system as physicians. If they wish to fulfill the role of primary care provider and autonomous practitioner, physiotherapists will need to hold themselves to comparably high standards of competence assessment and demonstration.
10. Is the clinical exam even valid and reliable?
The reliability, validity, and psychometric properties of the examination have been studied since the examination’s inception. The exam blueprint was developed based on foundational documents such as the national curriculum guidelines, the Physiotherapist Competence Profile, and the Analysis of Practice.
Examination questions are developed by a team of subject matter experts from across the country, and the question’s performance on each exam is carefully studied to ensure its reliability and validity. Questions that perform poorly are removed from the question bank. New questions are added to the bank as practice changes.
Each exam question is accompanied by a checklist that examiners use to score a candidate’s performance. Examiners also receive training regarding how to score the station they are assigned. These measures help to ensure that candidates’ performance is scored consistently, despite being tested by different examiners in different locations.
CAPR invests considerable resources into assuring the reliability and validity of the examination.
During the transition to the virtual examination, CAPR has taken steps to ensure that the same psychometric reliability and validity is achieved through the new examination process. More details about the psychometric properties of the exam can be found on CAPR’s website.
11. If the clinical examination is so important, why are you doing it virtually?
There are pros and cons of a virtual exam. Perhaps the most significant detractor is the common perception that one cannot assess clinical skills using a virtual or simulated environment.
Prior to the COVID-19 pandemic, CAPR, like other pre-licensure examination providers that typically include a clinical examination component in their examination process, was working to innovate examination processes. These organizations have all been challenged to accelerate the process of innovation process and re-think their exam processes due to the pandemic.
The Medical Council of Canada and Pharmacy Examining Board of Canada are two comparable Canadian organizations which have also been challenged by this issue. The Medical Council of Canada announced in February its plan to transition to a virtual examination in 2021 after postponing examinations in May and October 2020, and February 2021.
The shift to a virtual exam has an obvious short-term benefit of limiting the risk of COVID-19 exposure during the examination for candidates, examiners, and standardized patients alike. This change is partly in response to safety concerns raised by examination candidates as CAPR prepared to run the November in-person clinical examination, which was ultimately postponed.
In the long-term, the virtual examination may also result in increased ease of access to the exam for candidates.
[Correction: A previous version stated that Australia administered a similar exam. The College of Physiotherapists of Alberta misunderstood the information provided by colleagues at the APHRA. We removed the error as soon as it was brought to our attention.]
12. Why doesn’t the College of Physiotherapists of Alberta develop its own exam to meet the needs of University of Alberta graduates and local PCE candidates?
Many questions arise when discussing any such change including:
- How would internationally-educated physiotherapists access the examination, or be vetted for inclusion as examination candidates?
- Which organizations have the necessary psychometricians and other technical skills to ensure a reliable, valid, and sound examination?
- Which organizations have the clinical and technical skills to deliver a rigorous examination under usual circumstances?
- Which organizations, if any, could deliver a reliable, valid, and sound examination in the context of current COVID-19 restrictions?
- If provinces opt to employ a local approach to meeting the clinical competency examination requirement, what implications could this have on future labour mobility between provinces? Interprovincial labour mobility was one of the drivers behind the development of the PCE to begin with.
Importantly, if the College of Physiotherapists of Alberta were to develop an examination of its own, it would require a significant investment of time, human, and financial resources. The College of Physiotherapists of Alberta does not have the technical capacity to develop an examination on its own and would require the services of external contractors to complete this work.
If we were to “go it alone” there would be considerable costs attached to developing the examination, and those costs would be passed on to current regulated members and exam candidates. A new examination would also take considerable time to develop and is not likely to be a quick solution to the current situation.
13. Why doesn’t the College of Physiotherapists of Alberta trust the results from the University of Alberta’s own end of program Objective Structured Clinical Examination (OSCE), the University of Alberta is an accredited program, isn’t it?
While some people may think of the PCE as the last two hurdles in a race, it is more accurate to think of the exam as two strands of rope in a large safety net, like the net that protects a trapeze artist.
The University of Alberta’s physiotherapy program, like other Canadian physiotherapy programs, is accredited by Physiotherapy Education Accreditation Canada (PEAC), and that accreditation signifies that the program has met the expectations established in PEAC’s accreditation standards. The program delivers instruction and conducts student performance assessments, including the end of program OSCE, as part of its work to address the accreditation standards.
Similarly, all Canadian physiotherapy programs follow the National Physiotherapy Entry-to-Practice Curriculum Guidelines, established by the Canadian Council of Physiotherapy University Programs. Finally, all physiotherapy regulators, including the College of Physiotherapists of Alberta have similar registration requirements such as good character and reputation requirements, and requirements that registrants graduate from accredited Canadian programs or demonstrate that their education is substantively equivalent.
Together, these different groups and requirements form the safety net that ensures that all physiotherapists practicing in Canada meet a shared, minimum expectation for knowledge and performance of the practice of physiotherapy. This protects the public interest in that when receiving physiotherapy care they can be assured that a certain level of competent care can be expected.
No one document, organization or set of standards or requirements alone can achieve this objective. Removing any strand of rope from the safety net weakens the protection it offers, eroding public safety and confidence in physiotherapists.
14. Why can’t my supervised practice hours count towards meeting registration requirements? Why can’t my supervisor vouch for me and "grandfather"/legacy me in?
The registration requirements are established in the Physical Therapists Profession Regulation. Implementing change to our governing legislation is not a nimble process. Making such a change has the potential to take years.
More importantly, practice hours or a supervisor reference alone lack the rigor, objectivity, reliability and validity of an examination process.
As a regulatory organization we know that not all supervisors and supervision arrangements are equal. Although the majority of physiotherapist interns and their supervisors are doing a good job of fulfilling their obligations in a very challenging time, the College of Physiotherapists of Alberta has received a number of complaints regarding the practice of physiotherapist interns. We also hear from supervisors who, through their comments and questions, make it clear that they are not aware of their ongoing responsibilities.
Having supervisors and supervised practice hours serve in place of the clinical competency examination also has the potential to place supervisors in a conflict of interest. This would be problematic not only for the supervisor, but also from the perspective of assuring the public of the validity of the registration process.
There may also be equity and fairness considerations as some physiotherapist interns may not have secured and maintained full-time employment through the pandemic, impacting their ability to meet practice hours requirements or secure a supervisor reference.
Finally, most clinical environments do not encompass the breadth and depth of the Clinical Component of the PCE, which is designed to ensure that all physiotherapists entering practice do so with a shared, basic knowledge of the profession, regardless of where they anticipate their career path will lead.
15. But I have had to take time off to study and have lost earnings because of my ongoing status as a physiotherapist intern.
The PCE is a comprehensive, entry-to-practice examination that determines if candidates have met the entry-to-practice milestones set out in the Competency Profile for Physiotherapists in Canada. The College of Physiotherapists of Alberta recognizes that an exam of this importance takes preparation, both mental, financial, and otherwise, and for this reason we acknowledge the frustration caused when it was cancelled. And though we certainly would expect students to study in preparation for the examination, the decision to take time off work to study is a personal one, and not compulsory.
However, we are hearing many arguments from those that believe their education is superior and comprehensive such that a competency examination is not necessary while also claiming that the examination is too difficult and requires days of extensive preparation. Both arguments cannot be true at the same time. Again, we will state that a clinical competency examination approved by Council is a necessary and legislatively mandated step in proving competence (to date the only examination authorized by Council is the PCE). And the time spent preparing (as well as how you choose to prepare) will vary depending on your own personal decisions and circumstances.
While it is true that some employers pay a lower rate (either hourly or percentage of billings) for physiotherapist interns, that is a matter between the physiotherapist intern and their employer and should be addressed directly between the two parties. The College of Physiotherapists of Alberta has long held the perspective that physiotherapist interns are regulated members subject to the same Standards as any other regulated member and should be afforded the same employee rights and privileges.
[Correction: This question was updated to provide further context and clarity. We apologize for the confusion.]
16. Will information be sent to current supervising physiotherapists and employers about this current situation?
All regulated members of physiotherapy Alberta have received a message from the Registrar regarding the exam cancellation. Therefore, your supervisors should be aware of the situation.
The same message is posted on the College of Physiotherapists of Alberta’s website, and has been sent directly to the Most Responsible Physiotherapist identified for non-AHS clinical settings owned by non-physiotherapists and to physiotherapist leaders within AHS.
17. What would happen if I just didn’t bother to finish the examination process?
As already mentioned, under normal circumstances physiotherapist interns have a two-year time window in which to successfully complete the examination. After this time expires, they are no longer eligible to remain on the Provisional Register. Although the time frame for completion of the clinical examination has been extended in the wake of exam disruptions, it is not infinite.
Once examination services are resumed or an alternate registration process established, physiotherapist interns will be required to fulfill the requirements for registration within a defined period.
Practicing without a license is an offence under the Health Professions Act which carries significant fines and the risk of imprisonment.