Medical is always the last step when the positive decision is made but the paper work has not been finished to issue CoPR. The paperwork involves confirmation of receipt of the applicants PR approval from different departments within IRCC, RCMP and CBSA. Everyone must know you got your PR and must confirm they know. Imagine having dependents also! All the paperwork doubles, triples sometimes quadruples depending how many people are getting their PR. Single applicants are the fastest to process for obvious reasons.