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US Residencies and CaRMS

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I've been wondering about matching to US residencies. From what I understand, it comes with two risks: 1) if you match to a Canadian residency, you'll automatically be required to go there and 2) if you take an American residency, you might be at a disadvantage in terms of practicing in Canada? Are both of those presumptions true?

How does the ERAS match fit in with CaRMS? Would picking a US specialty as a top choice make me more likely to go unmatched (assuming the US residency is competitive, and I've reduced my chances at Canadian residencies due to my gamble at US residencies).

Am I correct at all? I'm an incoming M1, I really have no idea how most of these things work unfortunately.

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The problem is the CaRMS match happens first, so if you match to a Canadian residency program you will be automatically withdrawn from the American match. You don't get to match to a program in Canada, subsequently match to something in the US, then get to pick between the two. Basically, you have to not submit a rank-order list to CaRMS at all if you seriously want to match to the US; however, you then risk not matching in either country at all. It's a very risky move. In most cases, it's not feasible to apply to programs in both countries as you only have so much elective time in fourth year and have to focus on one match. And it goes without saying that CaRMS is becoming tighter every year. 

One thing you can do to get a sense of how strong an applicant you might be in the US is to take the USMLE step 1. If you score > 250, you can be reasonably sure of matching in the US as long as you're not applying to rads/ophthal/anesthesia/derm/plastics. 

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Reasons why Canadian medical students don't do residency in US:

1) You have to write the USMLE at some point during medical school, and it will be more difficult compared to the average US medical student because a) you don't have dedicated time to study and b) the premedical curriculum at US school teaches to the test, and you'd have to do a lot of stuff on your own at most Canadian schools.

2) Canadians who want to do residency in the states generally don't want to go to any program, they have specific programs in mind, and unless it's purely for location regions, they are generally prestigious, competitive programs, which will require a lot of time and energy to be competitive with your US counterparts, and again you're doing it on your own time.

3) You would have to do electives at your desired program(s) the US, which are more difficult to arrange, more expensive, and would take away from possible Canadian electives if you don't match to the US.

4) Unless you are a dual citizen, you will need a visa which is not necessarily easy to get.

5) The above mentioned system where the Canadian match is first, so you essentially have to give up the chance at matching in Canada in the first round to match to the US.

6) If you want to work in Canada, some residencies are different enough to their Canadian counterparts that you would require additional fellowship time to be able to be board certified in Canada.

7) You can do your residency in Canada and then take the USMLEs at your leisure and then usually you can work in both Canada and the US at that point.

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