Untrained And Unemployed: Medical Schools Churning Out Doctors Who Can't Find Residencies And Full Time Positions

[ralk]

I've been at this thread for too long and have repeated myself too many times, so I think it's time for a closing post on my part.

 

Here's my position: we should largely eliminate dedicated IMG residency positions and increase CMG medical school spots and residency positions to make up the difference. I take this position because I believe Canada should be training enough of ours own citizens to be physicians to meet our needs. Access to the medical profession should be based on qualities or attributes likely to lead to high-quality care for the patients who need it.

 

We should not rely on other nations to train physicians for us. Canada was once labelled a poacher of physicians and we have yet to fully shake that label. Relying on foreign-trained physicians has some financial benefits for Canada, but comes at a cost to the nations we take physicians from. As one of the wealthiest nations in the world with an ample supply of qualified aspiring physicians, we can and should be self-reliant.

 

In the past decade, a growing cohort of IMGs entering residency are actually Canadian-born and/or raised, so called CSAs. CSAs are predominantly Canadians who were unable to obtain a position in a Canadian medical school, either because they were rejected or because their academic qualifications are clearly below the requirements for these schools. The ability to study abroad is not based primarily on merit, but rather on willingness to pay the typically high costs of doing so. Allowing such a pathway to exist subverts the requirements put in place by Canadian medical schools meant to select the most qualified students, with consideration for the geographical distribution of future physicians and how that impacts Canadian patients' equitable access to physician services.

 

IMGs on the whole do not appear to be of higher quality than CMGs. Training insufficient numbers of CMGs and making up the difference with IMGs as we do now would have some merit if there was a gain in quality, but this is not the case. If anything, IMGs as a whole may be of slightly lower quality, though the data on that is not conclusive.

 

We are an immigration nation, so there should be a pathway for qualified, foreign-trained physicians to practice in Canada if they have completed their training as a physician, including post-graduate training, and that training is comparable to a Canadian residency program. This is roughly the same standard applied to all Canadian immigrants. Certification of these physicians should occur outside the residency system through any one of the many pathways currently available in Canada, though these pathways could be much improved in terms of equitable access, cost to applicants, and transparency. Elimination of IMG residency positions should not affect these already-qualified physicians, as any IMG that requires a full residency to practice competently in Canada has not received training that is comparable to a Canadian residency program.

 

I welcome criticisms or rebuttals of my position. However, I have addressed many counter-points to my position in this thread, in many instances more than once, and I would encourage posters to read through the whole thread in its entirety before providing an objection to one point or another. Therefore, unless a completely novel and compelling argument is presented, I will make this my final post, though I am happy to respond to PMs on this subject. As guy30 says, this thread has become fairly cyclical and so the benefit of me responding publicly seems fairly minimal at this point.

[guy30]

Ralk, I appreciate your closing post and the 2 large block of texts you've replied with lol.  I also do appreciate the thought you put into your posts and how you try to present a balanced and reasoned approach.  I guess it's just one of those agree to disagree type things for us until there is some sort of truly novel addition to this debate.

 

I am about to enter my clerkship years, however, I have had quite a bit of clinical experience as a health care worker prior to entering medical school. I've worked with CMGs, IMGs, CMG residents, IMG residents, you name it. So, thank you for your condescending remark on my experience, but I don't think it quite applies in my case.

 

I apologize if I sounded condescending, that was truly not my intention.  I just was not aware of your past experiences and I really was not meaning to sound abrasive.

 

 

The "CMGs apply 3 times" stat, while widely reported, doesn't actually appear to be true. The best direct data I could find on the subject puts the number at around 1.6 applications before getting in, with 85% of new medical students entering on their first or second application cycle. This is comparable to the rate CSAs apply before going overseas. There is a large self-selection bias in the CSA population as well - it's fairly easy to tell if you have no chance at Canadian Medical Schools. A substantial majority of CSAs indicate that they go overseas because they cannot enter medical school in Canada so no, their academic qualifications are not at the level of the CMGs who they would be compared against in Canadian medical school admissions.

 

The CMG having applied 3 times on average stat comes from the CARMS 2010 CSA report which references the 2009 Canadian Medical Education Statistics Report from the AFMC.  In the report for Table 75, 'Applications to Canadian Faculties of Medicine by Number of Applications Filed', the stat for the 2006/2007 year (2007/2008 was not available yet at the time of the report I think) showed the average number of applications for CMG's was 2.95 times out of a total of 31, 509 applications.  So this is likely where the applied 3 times on average number comes from.  Interestingly enough, there were over 200 people that applied ten times or more with one person that year having applied 16 times!  Yikes.  Also the stats interestingly highlight that the success rate for CMG's who were first time applicants in 2007/2008 was 20.3% and for repeaters was 24.6%.

 

 

We are an immigration nation, so there should be a pathway for qualified, foreign-trained physicians to practice in Canada if they have completed their training as a physician, including post-graduate training, and that training is comparable to a Canadian residency program. This is roughly the same standard applied to all Canadian immigrants. Certification of these physicians should occur outside the residency system through any one of the many pathways currently available in Canada, though these pathways could be much improved in terms of equitable access, cost to applicants, and transparency. Elimination of IMG residency positions should not affect these already-qualified physicians, as any IMG that requires a full residency to practice competently in Canada has not received training that is comparable to a Canadian residency program.

 

 

The point I agree with you on (and have agreed with you on in the past) is the point on immigration.  Immigration absolutely does need to tie in substantially to practice ready physicians as determined by Canadian regulatory bodies otherwise we're just creating more of a problem for ourselves.  And these physicians will likely come from comparable health systems which means we generally won't be 'poaching' physicians from developing nations then.

 

The rest, agree to disagree 

[ralk]

I apologize if I sounded condescending, that was truly not my intention.  I just was not aware of your past experiences and I really was not meaning to sound abrasive.

 

 

 

The CMG having applied 3 times on average stat comes from the CARMS 2010 CSA report which references the 2009 Canadian Medical Education Statistics Report from the AFMC.  In the report for Table 75, 'Applications to Canadian Faculties of Medicine by Number of Applications Filed', the stat for the 2006/2007 year (2007/2008 was not available yet at the time of the report I think) showed the average number of applications for CMG's was 2.95 times out of a total of 31, 509 applications.  So this is likely where the applied 3 times on average number comes from.  Interestingly enough, there were over 200 people that applied ten times or more with one person that year having applied 16 times!  Yikes.  Also the stats interestingly highlight that the success rate for CMG's who were first time applicants in 2007/2008 was 20.3% and for repeaters was 24.6%.

 

Ok, that deserves one last post

 

Thank you for clarifying your post - for my part, I apologize for my snarky response.

 

The 2.95 figure in Table 75 only says that applicants applied to, on average, 2.95 schools during that application cycle. That includes all applicants, successful or not, and does not include total lifetime applications per applicant over multiple cycles (that number was 3.87 and can be found in Tables 118 and 120).

 

The number of actual cycles applicants apply before being successfully admitted isn't explicitly stated as far as I can tell, but Table 111 lists the number of applicants admitted based on the first time they applied. Making the assumption that applicants apply every cycle until they get in, that leaves 1.62 cycles on average for admissions (the actual number will be slightly lower as some admitted individuals do not apply every year between their first application and their successful application). The CaRMS CSA report makes an erroneous apples-to-oranges comparison in reporting the 2.95 figure.

[3change]

...

[older]

 

1.  We should not rely on other nations to train physicians for us. Canada was once labelled a poacher of physicians and we have yet to fully shake that label. Relying on foreign-trained physicians has some financial benefits for Canada, but comes at a cost to the nations we take physicians from. As one of the wealthiest nations in the world with an ample supply of qualified aspiring physicians, we can and should be self-reliant.

 

2. In the past decade, a growing cohort of IMGs entering residency are actually Canadian-born and/or raised, so called CSAs. CSAs are predominantly Canadians who were unable to obtain a position in a Canadian medical school, either because they were rejected or because their academic qualifications are clearly below the requirements for these schools. The ability to study abroad is not based primarily on merit, but rather on willingness to pay the typically high costs of doing so. Allowing such a pathway to exist subverts the requirements put in place by Canadian medical schools meant to select the most qualified students, with consideration for the geographical distribution of future physicians and how that impacts Canadian patients' equitable access to physician services.

 

 

 

Although it is your closing post, you make new contentious statements. 

 

1. Nobody ever suggested that Canada should "rely on other nations" to train physicians for us. Either you are barking the wrong tree or willingly twist the discussion. The issue was, and remains,  whether or not to allow the relatively insignificant number (with relation to the total Canadian med work force) of IMGs and CSAs to enter the profession, or to slam the door. You are entitled to advocate the latter, but don't make it a different issue.

 

2. When labeling CSAs as rejects or unable to meet requirements, you conveniently omit the increasing number of CSAs who go abroad not because they are unable to study here in Canada, but who are simply fed up with the absurdity of the Canadian system. When going to med school straight from high school (which is the ever-proven model of med education in the majority of the developed world), they still need excellent grades to qualify, but they bypass the useless undergrad degree, GPA craze, and mind-boggling, manipulative Canadian admission system, whilst getting first-class, 6-year med education.  I am talking about studying in accredited schools in the countries like Ireland and UK, not in Carribean. It is true that this is costly alternative and thus not available to all, but makes a lot of sense for people with common sense who know early in the game what they want to do. Obviously those who went through all the hoops here, i.e.  applying on average 3 times and accumulating  2nd degrees, masters etc (and how is this affordable?!), would be resentful because they feel that the others jump the queue and have it "easy". But at the end what counts is to have fully qualified, quality physicians in our system -accumulating tons of sweat in the bucket while achieving those qualifications is simply not necessary and it should not be a virtue per se, as some are trying to make it. You continue to blast people for pursuing available options.  Working hard and smart is certainly better than just working hard.    

 

[GrumpyMoriarty]

2. When labeling CSAs as rejects or unable to meet requirements, you conveniently omit the increasing number of CSAs who go abroad not because they are unable to study here in Canada, but who are simply fed up with the absurdity of the Canadian system. When going to med school straight from high school (which is the ever-proven model of med education in the majority of the developed world), they still need excellent grades to qualify, but they bypass the useless undergrad degree, GPA craze, and mind-boggling, manipulative Canadian admission system, whilst getting first-class, 6-year med education.  I am talking about studying in accredited schools in the countries like Ireland and UK, not in Carribean. It is true that this is costly alternative and thus not available to all, but makes a lot of sense for people with common sense who know early in the game what they want to do. Obviously those who went through all the hoops here, i.e.  applying on average 3 times and accumulating  2nd degrees, masters etc (and how is this affordable?!), would be resentful because they feel that the others jump the queue and have it "easy". But at the end what counts is to have fully qualified, quality physicians in our system -accumulating tons of sweat in the bucket while achieving those qualifications is simply not necessary and it should not be a virtue per se, as some are trying to make it. You continue to blast people for pursuing available options.  Working hard and smart is certainly better than just working hard.    

 

 

1) I would hardly call the direct-entry from high school model in other countries a ever-proven model... do you have studies to back that up? Personally, I didn't realize that I want to pursue medicine until AFTER high school, so for many others like me, we would have been completely cut out of a chance to go to medical school and pursue that career path under the 6 year undergrad model.

 

2) There's nothing working smart about taking an easy way out just because one cannot hack it in the Canadian medical school admissions system. Are you telling me that if I take a look at the admissions statistics for Irish/Australian schools for international students, I would not find that the GPA/EC/other admissions requirements would be much lower and that the tuition would be much MUCH higher than for Canadian medical schools? Furthermore, these medical programs are not LCME accredited, which generally mean that canadian evaluators have not actually visited the schools and gotten a chance to directly gauge how well those medical programs are meeting canadian/american standards. So to the best of my knowledge, we are to accept the medical school's word that they are sufficiently training their MD candidates? Because no medical school has ever fudged things right?

 

3) You also fail to mention that one of the primary reasons why most CSAs aren't even attempting to practice in the country that taught them medicine is not entirely due to patriotic sentiments. They are not even offered residency programs at all in the country that taught them medicine. So if the country that provided them all that education and clerkship training wouldn't give them a chance at post-graduate training, why should Canada be required to do so?

[guy30]

1) I would hardly call the direct-entry from high school model in other countries a ever-proven model... do you have studies to back that up? Personally, I didn't realize that I want to pursue medicine until AFTER high school, so for many others like me, we would have been completely cut out of a chance to go to medical school and pursue that career path under the 6 year undergrad model.

 

 

6 year undergrad medicine models generally have a high school entry and a graduate entry route for people like yourself who don't realize they want to pursue medicine until after high school.  The 6 year undergrad model is proven in the sense that it's the original medical training model that physicians have been training in throughout history.  Not necessarily a better model but your assertion that this completely cuts out your chance to go to medical school is incorrect.

 

 

2) There's nothing working smart about taking an easy way out just because one cannot hack it in the Canadian medical school admissions system. Are you telling me that if I take a look at the admissions statistics for Irish/Australian schools for international students, I would not find that the GPA/EC/other admissions requirements would be much lower and that the tuition would be much MUCH higher than for Canadian medical schools? Furthermore, these medical programs are not LCME accredited, which generally mean that canadian evaluators have not actually visited the schools and gotten a chance to directly gauge how well those medical programs are meeting canadian/american standards. So to the best of my knowledge, we are to accept the medical school's word that they are sufficiently training their MD candidates? Because no medical school has ever fudged things right?

 

I mentioned this before already but I don't get why there is so much negativity towards obtaining an international education.  Experiences abroad, particularly in developed countries with comparable health systems, can be enriching, add value and diversity to Canada's health system as has been occurring for the last 30+ years with approximately 25% of the Canadian physician workforce being an IMG (and probably a higher percentage before that).  In comparison to other fields, I think the Canadian workforce is greatly enhanced with foreign engineers, architects, researchers, business leaders/accountants etc. that have passed Canadian equivalency exams and are now working in Canada.

 

Your post here gives off the sense that "we who train in Canada are so much better than everyone else in the world" which is simply not true.  Many of those people that couldn't 'hack it' in the Canadian medical admissions system may simply be a victim of regionalism and the 'lottery' that is Canadian med admissions across Canada depending on where you grew up in.  I would argue that the majority of these people who can't 'hack it' would be accepted if they were local students in a US medical school simply due to the sheer volume and variety of med schools down south compared to in Canada (and yes, the tuition rates in US schools can be equally shocking and actually quite close to those of overseas schools as well).  I would also argue that GPA's/EC's/other admissions requirements would possibly be slightly lower than certain ultra-competitive Canadian schools, but similar to other Canadian schools with lower in-province admissions GPA's (Saskatchewan ranging from 82%-95%, Manitoba ranging from 75%-92%, certain Quebec schools which I think I read in another thread is at about a 3.5 GPA which is a 75%-79%?).  

 

As I mentioned before, when admissions AVERAGES are getting to the 3.95 range in competitive provinces, the people with 3.8's or 3.7's end up going somewhere and sometimes this is to overseas schools with comparable health systems such as Australia, the UK, and Ireland.  In fact, there are probably more similarities in health systems between those countries and Canada as opposed to the US (a completely private system) which oddly shares accreditation with Canada (a public system) despite this.  What is more important than GPA's in the end is how one scores as a physician which is measured through test scores (still not a perfect measure but better than undergraduate GPA's).  The CSA's that do make it either back to Canada or the USA in fact need to do much better than their domestic counterparts on test scores (particularly for the USMLE in the US) so arguably, this is a better measure of who should enter the North American training pathway.  The reason why people go overseas is varied.  For the CSA CARMS study, other than the numerous other flaws people have already pointed out, is from a self-selected population so the reasons you see on there are also self-selected.  I certainly did not go overseas just because I couldn't 'hack it.'

 

The LCME accredits medical schools in the US and Canada. Are you suggesting that the problem lies in the fact evaluators haven't visited overseas schools so they should therefore go the route of dentistry and also accredit schools in Australia and Ireland to correct this problem?  If dentistry schools in Australia and Ireland are accredited by Canada, you'd think the medical schools would not be far off so be careful what you're implying!  It is absurd to suggest that medical schools in developed countries are not sufficiently training MD candidates and that they somehow fudge things.  Do you think Canada is the only place that knows how to train medical students in the world?  All of these developed countries are accredited by national accreditation bodies at a high standard and their accreditation standards are easily accessible to determine if they are meeting requirements.

 

 

3) You also fail to mention that one of the primary reasons why most CSAs aren't even attempting to practice in the country that taught them medicine is not entirely due to patriotic sentiments. They are not even offered residency programs at all in the country that taught them medicine. So if the country that provided them all that education and clerkship training wouldn't give them a chance at post-graduate training, why should Canada be required to do so?

 

I don't know how it works in the UK or Ireland but there are actually a good number of opportunities for internship and residency training in Australia for international students.  Yes there is an ever decreasing number of available spots each year and post-graduate training is not guaranteed but there are still a whole lot, the match rate is quite high compared to Canada, and I haven't yet met an international student who hasn't obtained a training place after graduation at my school.  This is probably why so many people end up staying in Australia so you are wrong in your assertion that the country that trained them won't give them post-graduate training.

 

Canada should be required to at least give some sort of access (as opposed to outright banning which was what was talked about earlier) for CSA's and in fact all IMG's because these are Canadian citizens who should be given the opportunity to pursue employment and post-graduate training (which is what a residency encompasses) just like any other Canadian in this country that passes the licensing/equivalency requirements set out by the Canadian regulatory bodies.  Nobody is saying that CMG's should not get residency positions but simply that extra capacity in the system also be made available to non-Canadian grads which is what currently occurs.  How the allocations system occurs is a different matter.  This doesn't seem to be an issue for most other fields when appropriate exams and licensing requirements are met in Canada but this seems to be a constant contention for even allowing people to pursue employment and post-graduate training when it comes to medicine.

[older]

_{Excellent answer and a coda to the discussion.}  

[amichel]

Slightly off topic. But I can't stand when people call admissions in Canada a "lottery". Yes, there is an element of luck involved. But to call it a lottery implies that the applicant has no ability to influence the outcome. Which is BS. Yes it's competitive. But if you have a strong GPA, decent MCAT and ECs, you will get into med school, likely on your first try. I think the number of people running around with good stats that don't get in anywhere is hugely exaggerated sometimes.

[NLengr]

I think calling it a "lottery" isn't really correct. Like you say, there is a small element of chance, but it's certainly not the biggest, or even significant factor.

 

What is likely true is that there are far more qualified applicants than spots. Many of the applicants who aren't offered admission would make good physicians. How much that group overlaps with CSA's is the million dollar question.

[guy30]

Slightly off topic. But I can't stand when people call admissions in Canada a "lottery". Yes, there is an element of luck involved. But to call it a lottery implies that the applicant has no ability to influence the outcome. Which is BS. Yes it's competitive. But if you have a strong GPA, decent MCAT and ECs, you will get into med school, likely on your first try. I think the number of people running around with good stats that don't get in anywhere is hugely exaggerated sometimes.

 

 

I think calling it a "lottery" isn't really correct. Like you say, there is a small element of chance, but it's certainly not the biggest, or even significant factor.

 

Kinda sucks being generalized and painted with a broad brush stroke eh?  The term lottery was put in quotations to highlight the fact that there are far more qualified applicants than there are Canadian medical school positions (therefore it's become standard for many people to have to apply multiple times), and the effect regionalism has on an equally qualified applicant getting admission growing up in one part of the country but not in another part.  Yes a strong GPA, decent MCAT and EC's will get you in, that's fair enough.  But what is considered a strong GPA nowadays, an A+?  What about those that get an A, A-, and even a B+ that get in while others don't.  More importantly, how strongly does this actually correlate to being a good physician beyond a certain GPA?

 

Those that get admitted as CMG's can be a fairly diverse bunch and with varying admissions scores across Canada (that can be as low as 75% in some cases).  CSA's and particularly all IMG's are an even more diverse group and can't be all painted with the same broad stroke either.

 

 

What is likely true is that there are far more qualified applicants than spots. Many of the applicants who aren't offered admission would make good physicians. How much that group overlaps with CSA's is the million dollar question.

 

True, totally agree, but does that question matter?  In my experience (other than one particular school in Aus) there is some good overlap though people go abroad for a multitude of reasons.  What matters are the standards of the individual entering the system and whether they'd make a good physician IMO.

[GrouchoMarx]

Slightly off topic. But I can't stand when people call admissions in Canada a "lottery". Yes, there is an element of luck involved. But to call it a lottery implies that the applicant has no ability to influence the outcome. Which is BS. Yes it's competitive. But if you have a strong GPA, decent MCAT and ECs, you will get into med school, likely on your first try. I think the number of people running around with good stats that don't get in anywhere is hugely exaggerated sometimes.

 

It is still kind of a lottery. You need money to buy a ticket but there's no guarantee you'll win, same way that you need the killer app to have a chance at admission, but its still no guarantee.

 

The Canadian IMGs are buying fake lottery tickets but the numbers still win in some cases.

 

We should stop using the term CSA. It defines them by their passport nation, not by the nation in which they obtained their medical training. There was a Korean guy in my med school class. Should we say he was a KSA?

[amichel]

It is still kind of a lottery. You need money to buy a ticket but there's no guarantee you'll win, same way that you need the killer app to have a chance at admission, but its still no guarantee.

 

The Canadian IMGs are buying fake lottery tickets but the numbers still win in some cases.

 

We should stop using the term CSA. It defines them by their passport nation, not by the nation in which they obtained their medical training. There was a Korean guy in my med school class. Should we say he was a KSA?

Yah but in a lottery the only thing you can do to increase your odds is buy more tickets. That's not how admissions work.

[武田信玄]

It is still kind of a lottery. You need money to buy a ticket but there's no guarantee you'll win, same way that you need the killer app to have a chance at admission, but its still no guarantee.

 

The Canadian IMGs are buying fake lottery tickets but the numbers still win in some cases.

 

We should stop using the term CSA. It defines them by their passport nation, not by the nation in which they obtained their medical training. There was a Korean guy in my med school class. Should we say he was a KSA?

Like a Korean without Canadian citizenship/PR card? Well if he got into a Canadian med school as an international student, then 1.good for this person and 2.he is a CMG.

[Arztin]

I know this thread has been dormant for a little while - but I recently checked the Ross website and saw three matches into UofT family and internal (6 total to uoft). now I don't know how many mcgill grads matched into uoft, but there is at least one who couldn't match into FM . And I realize, that this was possibly a dedicated stream, etc... Nonetheless, one is forced into a couple of conclusions based on the outcome of the general policy: a) admission based on high gpa and mcat scores doesn't really matter for clinical performance; or b] the training at Ross is much better than the training at McGill in terms of clinical readiness despite the possible lesser caliber of student based traditional admission metrics. Now I realize that this is a sample size of one, and that many people felt he  have tried to really back-up toronto - but why is that? I mean a Ross graduate by that reasoning should never try Toronto, but many do and are successful... A great deal of interesting discussion resolved around ethics of studying abroad etc,, but I'd like to understand this case a bit better and appreciate any thoughts. Just for reference stats at Ross - avg gpa on admission is 3.2 and mcat 24. When Mcgill had the mcat it was avg 32 and gpa my guess about 3.8.

 

The stats don't mean much for special cases. They are the exception rather than the norm. 

For IMG who go to ROSS SABA SGU, they have to be realy friggin good (or have contacts?) to match back in Canada.

As for those from McGill who couldn't match in FM, I'll just put it this way to preserve their confidentiality, one candidate was extremely undesirable for any field because of something they have done, while the other has not ranked enough programs.

 

a) admission based on high gpa and mcat scores doesn't really matter for clinical performance; -------programs.Yeah regarding this, it has been scientifically studied and acknowledged a while ago. Hence, MMI was developped and implemented to overcome this problem. Good UG GPA correlates with good preclerk GPA, but not so much with clinical performance.

 

b] the training at Ross is much better than the training at McGill in terms of clinical readiness despite the possible lesser caliber of student based traditional admission metrics.We have here a small number of candidates from SABA. To match back in Canada, you just have to be extra good when you went South to get your MD. Also, they might have had contacts? Who knows? Also, most students from McGill are IP. They are therefore more prone to rank home province programs rather than programs from elsewhere. I don't think it's fair to just start comparing programs based on a small number that doesn't mean much. 

[JohnGrisham]

Dedicated streams.