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

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[guy30]

I just had a read through this thread and it is quite interesting and entertaining to say the least!

 

There's been a lot of posts about getting rid of the parallel system of IMG's being in the first iteration for CaRMS and going back to the old system where IMGs are only allowed into the 2nd iteration.  However, I don't know all the specific details but just to give some background to this, the original change to the CaRMS system of creating a parallel stream just for IMG's was made back in 2007 I believe after a court ruling that determined that only allowing IMG's to enter in the 2nd iteration was discriminatory particularly since all people who enter into CaRMS are either Canadian citizens or at the very least, permanent residents.  So this may have been a discrimination based on country of origin type thing or something similar and I think was even found to be a Charter of Rights violation though I'm not sure?

 

In the end, instead of CaRMS opening the flood gates and moving to a US style system where all CMGs and IMGs compete together in the 1st iteration for the same residency places, they created a parallel stream in order to guarantee that all CMGs will have access to guaranteed residency positions within their stream, but that residency positions are also allocated to the IMG stream in the 1st iteration of the match.

 

Because of this background to the change, I don't think going back to the old system where IMGs are only allowed into the 2nd iteration would be possible/probable.

[PCT6TH]

I have two problems with introducing foreign doctors in our current situation.

 

1. A very common argument FOR introducing foreign doctors based on practicality is that it takes a lot of Canadian taxpayers' money to train doctor. Better to have some other countries to train doctors for us and then we pick the top of their cream. This way we save money. But I'm not sure if my logic is tight here, but if we follow this argument, then we might as well replace all our doctors with foreign doctors. This way we don't even need to spend a single cent on medical school. Or at the very least, I would buy this argument more if I actually saw a decrease in our Canadian medical school spots. But I see the opposite. Instead, we are pumping more money into our medical school to pump out more graduates, and yet introducing more IMGs to compete with the unchaning residency spots. This to me just doesn't make any sense. How is doing this going to save our tax money? Please point out the flaw of my logics here.

 

2. Another very common argument, also based on practicality, is that our CMGs don't have enough passion to go to rural areas and to serve under-served populations. Therefore, we can introduce IMGs and force them to work in those areas for an x amount of years before they can return to other parts of the country to practice. Again I would buy this argument more if this were actually the case. However, I am just going to quote something from the reading materials in this thread:

 

http://forums.premed101.com/index.php?/topic/78064-how-i-improved-my-mmi/

 

One of the documents (I think it's some federal government report or something) specifically says "IMGs are expected to work in rural areas but unfortunately they rarely do". So if we don't enforce the rule, this second argument is useless.

 

People may argue that we cannnot treat IMGs like slaves and force them to live in certain areas and this is against human rights and blah blah blah. You have to remember by coming to Canada, these IMGs are getting paid way better than in their home countries (usually). So I see it as a fair trade-off. Nobody is forcing them to come to Canada. Besides, the supposed rule only requires them to stay in rural areas for a few year, not forever.

I don't know if somebody have already pointed this out or no, but IMG's sign a contract before starting residency that clearly states that they will be forced to work in under-served areas for the same number of years that they have spent in residency ............. it is called return of service ........... you can look it up on CaRMS ........

[ralk]

I just had a read through this thread and it is quite interesting and entertaining to say the least!

 

There's been a lot of posts about getting rid of the parallel system of IMG's being in the first iteration for CaRMS and going back to the old system where IMGs are only allowed into the 2nd iteration.  However, I don't know all the specific details but just to give some background to this, the original change to the CaRMS system of creating a parallel stream just for IMG's was made back in 2007 I believe after a court ruling that determined that only allowing IMG's to enter in the 2nd iteration was discriminatory particularly since all people who enter into CaRMS are either Canadian citizens or at the very least, permanent residents.  So this may have been a discrimination based on country of origin type thing or something similar and I think was even found to be a Charter of Rights violation though I'm not sure?

 

In the end, instead of CaRMS opening the flood gates and moving to a US style system where all CMGs and IMGs compete together in the 1st iteration for the same residency places, they created a parallel stream in order to guarantee that all CMGs will have access to guaranteed residency positions within their stream, but that residency positions are also allocated to the IMG stream in the 1st iteration of the match.

 

Because of this background to the change, I don't think going back to the old system where IMGs are only allowed into the 2nd iteration would be possible/probable.

 

I looked around for that lawsuit and couldn't find any concrete evidence it actually happened. Apparently neither could people when it supposed happened. Some of the commentators at the time mention a threat of a lawsuit, but not necessarily a lawsuit itself. Hard to see how the current system would be the product of a successful discrimination suit, since separate-but-equal hasn't held judicial weight for decades and the distinction between IMG and CMG has nothing to do with country of origin (there are plenty of foreign-born CMGs and Canadian-born IMGs). There are several specialties without any IMG spots at all in the country, not to mention the many programs without IMG positions. The current system clearly does not provide equal access for IMGs.

 

Switching to a 2nd-iteration only system, on it's own, wouldn't change how many IMGs could match to residencies, but rather where they could match, which the current system already restricts. As for discrimination, there is a clear merit-based differentiation: graduation from an LMCC-accredited institution. 

 

Going back to the old system isn't likely for political reasons, but I really can't see how it would be a Charter violation unless the current system also violates the Charter.

[guy30]

I looked around for that lawsuit and couldn't find any concrete evidence it actually happened. Apparently neither could people when it supposed happened. Some of the commentators at the time mention a threat of a lawsuit, but not necessarily a lawsuit itself. Hard to see how the current system would be the product of a successful discrimination suit, since separate-but-equal hasn't held judicial weight for decades and the distinction between IMG and CMG has nothing to do with country of origin (there are plenty of foreign-born CMGs and Canadian-born IMGs). There are several specialties without any IMG spots at all in the country, not to mention the many programs without IMG positions. The current system clearly does not provide equal access for IMGs.

 

Switching to a 2nd-iteration only system, on it's own, wouldn't change how many IMGs could match to residencies, but rather where they could match, which the current system already restricts. As for discrimination, there is a clear merit-based differentiation: graduation from an LMCC-accredited institution. 

 

Going back to the old system isn't likely for political reasons, but I really can't see how it would be a Charter violation unless the current system also violates the Charter.

 

Yeah I did a bit of searching and it's quite difficult to find info on this since it was such a long time ago and many of the online news article links just don't exist anymore.  You can do more of your own searching into this but from what I could find...

 

In 2002, there was a successful human rights complaint brought against the BC Council of Human Rights by 5 IMG doctors (filed in 2001) and this also involved 2 of the doctors going on a hunger strike.

In 2004-2005, there was another successful human rights complaint brought against the Manitoba Human Rights Commission by an IMG doctor and the Association of Foreign Medical Graduates of Manitoba after the case went to adjudication (case filed in 1999).

In 2004/2005, there was a class-action that was filed with the Ontario Human Rights Commission by IMG doctors as well regarding the process of matching/accreditation. 

 

These are mainly anecdotes I could find since much of the information is quite old now but I imagine CaRMs ended up trying to get ahead of the curve by pre-emptively creating a parallel match system in 2006 and implementing it in 2007?

[ralk]

Yeah I did a bit of searching and it's quite difficult to find info on this since it was such a long time ago and many of the online news article links just don't exist anymore.  You can do more of your own searching into this but from what I could find...

 

In 2002, there was a successful human rights complaint brought against the BC Council of Human Rights by 5 IMG doctors (filed in 2001) and this also involved 2 of the doctors going on a hunger strike.

In 2004-2005, there was another successful human rights complaint brought against the Manitoba Human Rights Commission by an IMG doctor and the Association of Foreign Medical Graduates of Manitoba after the case went to adjudication (case filed in 1999).

In 2004/2005, there was a class-action that was filed with the Ontario Human Rights Commission by IMG doctors as well regarding the process of matching/accreditation. 

 

These are mainly anecdotes I could find since much of the information is quite old now but I imagine CaRMs ended up trying to get ahead of the curve by pre-emptively creating a parallel match system in 2006 and implementing it in 2007?

 

From what I can tell, none of those cases involved the CaRMS match, but accreditation outside of CaRMS. The first and third cases at least appear to concern accreditation exams not associated with residencies. The second seems to be a bit of both, but ultimately was against authorities in Manitoba, not CaRMS policy itself. In any case, it's hard to see how CaRMS parallel system actually defends them against any such complaints, because the current system really doesn't afford any guarantees to practicing as a physician for IMGs that the old system didn't.

 

There's another explanation for the change to IMG streams: physician shortages. Around that time, there was a perception that we had a significant physician shortage. Since Canada was actively recruiting IMGs to fill that gap, it would make sense to streamline the process by running IMGs through much the same process CMGs went through. We wanted them anyway, might as well make it easier for them to go through the process.

 

But that situation has now changed. Domestic enrollment rapidly expanded to fill the gap. While there are still certainly shortages in some areas and fields, there are job shortages in others, and with increasing pressure to restrain healthcare costs, the need for IMGs in Canada has been substantially reduced. Current medical systems are already responding to this changing situation - while CMG spots have mostly kept pace with demand (a bit below historical ratios, but still above a 1-to-1 ratio), IMG spots are holding steady or even going down somewhat, despite rapidly rising demand. Again, it's hard to view CaRMS' set-up as a hedge against future litigation when it clearly treats IMGs differently than CMGs.

[guy30]

From what I can tell, none of those cases involved the CaRMS match, but accreditation outside of CaRMS. The first and third cases at least appear to concern accreditation exams not associated with residencies. The second seems to be a bit of both, but ultimately was against authorities in Manitoba, not CaRMS policy itself. In any case, it's hard to see how CaRMS parallel system actually defends them against any such complaints, because the current system really doesn't afford any guarantees to practicing as a physician for IMGs that the old system didn't.

 

There's another explanation for the change to IMG streams: physician shortages. Around that time, there was a perception that we had a significant physician shortage. Since Canada was actively recruiting IMGs to fill that gap, it would make sense to streamline the process by running IMGs through much the same process CMGs went through. We wanted them anyway, might as well make it easier for them to go through the process.

 

But that situation has now changed. Domestic enrollment rapidly expanded to fill the gap. While there are still certainly shortages in some areas and fields, there are job shortages in others, and with increasing pressure to restrain healthcare costs, the need for IMGs in Canada has been substantially reduced. Current medical systems are already responding to this changing situation - while CMG spots have mostly kept pace with demand (a bit below historical ratios, but still above a 1-to-1 ratio), IMG spots are holding steady or even going down somewhat, despite rapidly rising demand. Again, it's hard to view CaRMS' set-up as a hedge against future litigation when it clearly treats IMGs differently than CMGs.

 

I also agree that a parallel system doesn't defend them from such complaints on fairness etc. to human rights commissions.  Probably still more palatable for CaRMS in the end than risking larger numbers of CMG's not obtaining a residency in an open match system like what is present in the US (though arguable a more 'fair' system since it involves open competition and is more merit based).

 

In terms of the old system of IMG's only having access to the 2nd iteration match and how you considered this to be a merit-based differentiation due to graduates being from a LMCC med school vs others that are not, I don't think that that assertion is necessarily defensible to the original human rights complaints either.  This is due to the fact that regulatory bodies have created a process (MCCEE, MCCQE, national OSCEs, MMI, interviews etc.) to evaluate graduates of non LMCC schools and determine whether they are at the level of what is expected of a LMCC graduate eligible to enter into first year residency and CaRMS.  If individuals pass through this process created by the regulatory bodies, then it can be argued that including some Canadian citizens while excluding others for access to residency in the 1st iteration is in fact not fair.  A true merit-based differentiation would be to have an open match for all qualified candidates in the match regardless of medical school.

 

Now this is only purely talking about the concept of 'fairness' in the match of course in the context of the law suites/human rights complaints we were talking about before and not talking about all the other issues such as tax-payer funded education and getting a return on this investment etc.  But I would argue that what is best for patients and most fair is a truly merit-based match by candidates chosen by residency directors regardless of medical school as long as they are determined to be qualified to enter first year residency.  If present, issues with language, culture, relating to patients etc. can be screened for at the residency director level and via prior testing at the OSCE, MMI, and Interview level.  If the 'superiority' of Canadian medical schools to all other medical schools in the world is true, then CMG's should have nothing to be worried about, and this largely holds true in the US for US grads when competing with IMGs.

 

I personally don't mind a parallel match however, there just needs to be more investment into residency positions which may require some systemic changes in how residency positions are funded (ie hospital vs. universities).  Also, another issue to address of course is how our immigration system works and tying that in to the training/accreditation system if we are going to select people based on their prior skills as a physician to come to Canada.  There's no point in selecting people for these skills when there is no way to train them or if it's not tied to accreditation so that they can work as soon as they arrive in the country.

[JohnGrisham]

Lol, for the Us match, it's not so that the U.S. grads don't worry because they are better - they don't worry because PDs and programs prefer US grads over IMGs in most places. Your line of thinking is a bit off, hope that helps.

[guy30]

Lol, for the Us match, it's not so that the U.S. grads don't worry because they are better - they don't worry because PDs and programs prefer US grads over IMGs in most places. Your line of thinking is a bit off, hope that helps.

 

Hey and preferencing your own grads is fair enough, it's what you're familiar with.  Either way, no need to worry then for CMGs in an open match system.  

 

In fact, if residency directors preference their own grads preferentially anyways, the current parallel system works to the advantage of IMGs in the end compared to an open match system.

[ralk]

I also agree that a parallel system doesn't defend them from such complaints on fairness etc. to human rights commissions.  Probably still more palatable for CaRMS in the end than risking larger numbers of CMG's not obtaining a residency in an open match system like what is present in the US (though arguable a more 'fair' system since it involves open competition and is more merit based).

 

In terms of the old system of IMG's only having access to the 2nd iteration match and how you considered this to be a merit-based differentiation due to graduates being from a LMCC med school vs others that are not, I don't think that that assertion is necessarily defensible to the original human rights complaints either.  This is due to the fact that regulatory bodies have created a process (MCCEE, MCCQE, national OSCEs, MMI, interviews etc.) to evaluate graduates of non LMCC schools and determine whether they are at the level of what is expected of a LMCC graduate eligible to enter into first year residency and CaRMS.  If individuals pass through this process created by the regulatory bodies, then it can be argued that including some Canadian citizens while excluding others for access to residency in the 1st iteration is in fact not fair.  A true merit-based differentiation would be to have an open match for all qualified candidates in the match regardless of medical school.

 

Now this is only purely talking about the concept of 'fairness' in the match of course in the context of the law suites/human rights complaints we were talking about before and not talking about all the other issues such as tax-payer funded education and getting a return on this investment etc.  But I would argue that what is best for patients and most fair is a truly merit-based match by candidates chosen by residency directors regardless of medical school as long as they are determined to be qualified to enter first year residency.  If present, issues with language, culture, relating to patients etc. can be screened for at the residency director level and via prior testing at the OSCE, MMI, and Interview level.  If the 'superiority' of Canadian medical schools to all other medical schools in the world is true, then CMG's should have nothing to be worried about, and this largely holds true in the US for US grads when competing with IMGs.

 

I personally don't mind a parallel match however, there just needs to be more investment into residency positions which may require some systemic changes in how residency positions are funded (ie hospital vs. universities).  Also, another issue to address of course is how our immigration system works and tying that in to the training/accreditation system if we are going to select people based on their prior skills as a physician to come to Canada.  There's no point in selecting people for these skills when there is no way to train them or if it's not tied to accreditation so that they can work as soon as they arrive in the country.

 

IMGs, even with the regulatory hurdles they have to jump through before applying for residencies, are still not measuring up to the same standard as CMGs on the whole. They have added a few new requirements the effect of which has yet to be measured, but with the data available it's not hard to make the argument that schooling at an LMCC-accredited school is, in itself, a qualification, independent of the other considerations. Residency directors already try to get the best IMG candidates they can with every available metric, so the evaluation system for IMGs clearly isn't reliable or robust in ensuring quality. That's not to say IMGs are bad physicians - there's a lot of variability with many excellent IMGs and many not-so-great IMGs - but since on average a CMG is likely to outperform an IMG, moving towards more CMGs and fewer IMGs, from what available evidence shows, is what is best for patients.

 

In any case, concerns about their quality are not why I would prefer to restrict IMG access to residency spots. I've made these points elsewhere in the thread, so I won't belabour them, but it really comes back to fairness:

 

1) Fairness for patients. CSAs, which comprise the majority of IMGs, tend to be from overserved communities, namely big metropolitan centres, and express a clear preference for working their. The ROS attached to their residency may force them to work somewhere else for a while, but most tend to move away when they can (though if we're talking legality of arrangements for IMGs, the standard ROS is quite vulnerable to a human rights challenge). Foreign-born IMGs also prefer major metropolitan centres, as most immigrants to Canada do. As Canada tries hard to find more physicians who want to work in rural or remote areas, IMGs circumvent the most evidence-based approach to filling that need we have - selecting medical students from those underserved areas.

 

2) Fairness of access to the medical profession. The CSA route is really only available to those who have families willing to take a large monetary risk on their career. Naturally, these tend to be wealthier students (and are more likely to be students with physicians as parents). Medicine already slants pretty heavily to wealthier students and those who grew up in a medical family and the growing number of CSAs make that slant worse. The CSA route is unfair to lower-income Canadians. Being more fair at the residency point makes the whole system less fair overall. It's admirable to want a merit-based system - that's what I want as well - but checking for merit if and only if a person can financially afford to get to that stage isn't a merit-based system. It's a plutocracy.

 

There's also the matter of ensuring that the return on the investment Canadian governments make in CMGs is reliable, but as Gohan points out, even a fully open system likely wouldn't leave a lot of CMGs without a residency position. With so many IMGs applying to Canada, an open system would see the vast majority of their applications thrown out by programs who could easily take their pick of CMGs - that's how many US programs do it.

 

I absolutely agree about the immigration system, which is a whole other mess.

 

I disagree about increasing investment into residency positions. We already increased physician numbers fairly substantially and provinces are increasingly unwilling to pay for those extra physicians. There's no point pumping through more physicians if we're unwilling to pay for their work. In more than a few fields we're seeing a decrease in residency numbers for that very reason.

[guy30]

IMGs, even with the regulatory hurdles they have to jump through before applying for residencies, are still not measuring up to the same standard as CMGs on the whole. They have added a few new requirements the effect of which has yet to be measured, but with the data available it's not hard to make the argument that schooling at an LMCC-accredited school is, in itself, a qualification, independent of the other considerations. Residency directors already try to get the best IMG candidates they can with every available metric, so the evaluation system for IMGs clearly isn't reliable or robust in ensuring quality. That's not to say IMGs are bad physicians - there's a lot of variability with many excellent IMGs and many not-so-great IMGs - but since on average a CMG is likely to outperform an IMG, moving towards more CMGs and fewer IMGs, from what available evidence shows, is what is best for patients.

 

In any case, concerns about their quality are not why I would prefer to restrict IMG access to residency spots. I've made these points elsewhere in the thread, so I won't belabour them, but it really comes back to fairness:

 

1) Fairness for patients. CSAs, which comprise the majority of IMGs, tend to be from overserved communities, namely big metropolitan centres, and express a clear preference for working their. The ROS attached to their residency may force them to work somewhere else for a while, but most tend to move away when they can (though if we're talking legality of arrangements for IMGs, the standard ROS is quite vulnerable to a human rights challenge). Foreign-born IMGs also prefer major metropolitan centres, as most immigrants to Canada do. As Canada tries hard to find more physicians who want to work in rural or remote areas, IMGs circumvent the most evidence-based approach to filling that need we have - selecting medical students from those underserved areas.

 

2) Fairness of access to the medical profession. The CSA route is really only available to those who have families willing to take a large monetary risk on their career. Naturally, these tend to be wealthier students (and are more likely to be students with physicians as parents). Medicine already slants pretty heavily to wealthier students and those who grew up in a medical family and the growing number of CSAs make that slant worse. The CSA route is unfair to lower-income Canadians. Being more fair at the residency point makes the whole system less fair overall. It's admirable to want a merit-based system - that's what I want as well - but checking for merit if and only if a person can financially afford to get to that stage isn't a merit-based system. It's a plutocracy.

 

There's also the matter of ensuring that the return on the investment Canadian governments make in CMGs is reliable, but as Gohan points out, even a fully open system likely wouldn't leave a lot of CMGs without a residency position. With so many IMGs applying to Canada, an open system would see the vast majority of their applications thrown out by programs who could easily take their pick of CMGs - that's how many US programs do it.

 

I absolutely agree about the immigration system, which is a whole other mess.

 

I disagree about increasing investment into residency positions. We already increased physician numbers fairly substantially and provinces are increasingly unwilling to pay for those extra physicians. There's no point pumping through more physicians if we're unwilling to pay for their work. In more than a few fields we're seeing a decrease in residency numbers for that very reason.

 

If the evaluation system for IMG's isn't reliable or robust enough to ensure people are qualified to enter first year residency, then that is an issue with the regulatory bodies and those bodies absolutely need to do their job in ensuring people are appropriately qualified to enter CaRMS... that is what they're there for.  However, I would note that IMG's already do the same exams as CMG's for licensure along with multiple other extra hurdles such as the NAC OSCE, MMI's, interviews etc. as mentioned before so I'm not sure what else can be done to further evaluate them as a group?

 

Also, I would argue that graduation from a LMCC institution is not in itself a qualification when people have been evaluated to the same level to enter CaRMS.  Particularly when it comes to developed countries like the UK or Australia, medicine is ultimately medicine and it can only differ so much at the med school level. Everyone uses the same textbooks and same evaluation methods in very similar clinical environments.  When it comes to basic medical education at the undergraduate level, there is very little that is different between medical students (which I've experienced first hand).  You can only learn your basic sciences in so many ways with the same textbooks, and for the 2 years of clerkship, everyone uses the same resources to study clinical medicine around the world including those to study physical examinations etc. and these teaching resources also come from all over the world (not just Canada).

 

In what sense are you saying that IMG's don't measure up to CMG's or that there is a serious deficiency in performance?  The only real metric I know is the difference in pass rates between IMG's and CMG's for the MCCQE exams.  If it is this metric you are referring to there are a couple issues with it.  One thing is that the pass rates don't say anything about the actual scores IMG's have that actually make it into CaRMS and match into residency.  I would imagine that these would be relatively high similar to the higher USMLE scores for IMG's needed in the US compared to US grads.  

The second thing is that I agree there is a lot of variability in IMG's as they are a very very diverse group of people.  Whereas the CMG pass rate is based on all graduating/recently graduated medical students from Canadian medical schools with knowledge and preparation fresh on their minds (a fairly narrow sample size and group), the IMG group includes people who have recently graduated, graduated 20 years ago,, people practising, people out of practice for 5-10 years, people who train in a first world country with very similar medical systems and/or medical education models as Canada such as USDO schools, the UK, or Australia, along with people who trained from developing nations like Iran, Afghanistan, or Zimbabwe (I have no idea if Zimbabwe has a medical school).  Of course the pass rate will be vastly different since the statistic is not stratified and is generalized to such a diverse group of people with just about anyone with a medical degree being eligible to take the exams.  All the people I know from the UK and Australia had done extremely well on the MCC exams and as far as I know, are also excellent residents.

 

You mentioned that CSA's make up the majority of IMG's, just off the top of my head, don't they only make up around 25% of those applying in CaRMS?  However, I absolutely agree with you that IMG's will often gravitate towards urban centers.  All the evidence around the world has shown this and also the fact that ROS agreements for IMG's don't work other than as a temporary fix.  You are also right that the evidence has shown that recruiting medical students from under-served areas is the best way of filling the physician need in those areas.  In fact, in Australia (I'm a domestic medical student in Australia but have grown up in both countries), in addition to increasing the number of clinical schools in rural areas and recruiting for more rural students (who then aren't required to obtain the same academic standards as urban students to take into account their 'ruralness' and the lack of academic supports etc they have access to compared to urban students), there are specific rural bonded places for domestic students that have a ROS attached to them. I think this makes up like 1/3 the number of domestic places in a medical school actually.

 

In terms of CSA's, I would argue that the majority of them are not particularly wealthy upper class people coming from big family money and that they are actually drawn from largely the same socio-economic group as CMG's since many of them came from the same group of people applying to medical school in the first place.  As others have pointed out, there are many ways to fund CSA education and it can be quite do-able (though with a significant risk component obviously) from government loans, LOC, to parental contributions/second mortgages etc..  The tuition is actually quite similar to that of US medical schools anyways.  As you mentioned, medicine/CMG's already slant towards wealthier students with many that grew up in a medical family.  As others have also pointed out, barriers are already put in place against low-income students going to Canadian medical schools in everything from access to study resources such as prep-courses for the MCAT, tuition for an entire undergraduate degree, application fees for admissions tests, application fees to multiple medical schools, travel across the country for interviews, etc. etc.

 

Lastly in regards to the number of residency places, I absolutely do agree that these need to match the need and distribution of specialities required in the physician market for Canada.  I'm not sure if there are some good numbers/data yet on how saturated or maldistributed residency training places are yet and unfortunately, there isn't really a national strategy or body in place to track and control this but it is something that is needed.

[116E118]

On 7/12/2015 at 9:45 AM, guy30 said:

In terms of CSA's, I would argue that the majority of them are not particularly wealthy upper class people coming from big family money and that they are actually drawn from largely the same socio-economic group as CMG's since many of them came from the same group of people applying to medical school in the first place.  As others have pointed out, there are many ways to fund CSA education and it can be quite do-able (though with a significant risk component obviously) from government loans, LOC, to parental contributions/second mortgages etc..  The tuition is actually quite similar to that of US medical schools anyways.  As you mentioned, medicine/CMG's already slant towards wealthier students with many that grew up in a medical family.  As others have also pointed out, barriers are already put in place against low-income students going to Canadian medical schools in everything from access to study resources such as prep-courses for the MCAT, tuition for an entire undergraduate degree, application fees for admissions tests, application fees to multiple medical schools, travel across the country for interviews, etc. etc.

 

.

[ralk]

If the evaluation system for IMG's isn't reliable or robust enough to ensure people are qualified to enter first year residency, then that is an issue with the regulatory bodies and those bodies absolutely need to do their job in ensuring people are appropriately qualified to enter CaRMS... that is what they're there for.  However, I would note that IMG's already do the same exams as CMG's for licensure along with multiple other extra hurdles such as the NAC OSCE, MMI's, interviews etc. as mentioned before so I'm not sure what else can be done to further evaluate them as a group?

 

Also, I would argue that graduation from a LMCC institution is not in itself a qualification when people have been evaluated to the same level to enter CaRMS.  Particularly when it comes to developed countries like the UK or Australia, medicine is ultimately medicine and it can only differ so much at the med school level. Everyone uses the same textbooks and same evaluation methods in very similar clinical environments.  When it comes to basic medical education at the undergraduate level, there is very little that is different between medical students (which I've experienced first hand).  You can only learn your basic sciences in so many ways with the same textbooks, and for the 2 years of clerkship, everyone uses the same resources to study clinical medicine around the world including those to study physical examinations etc. and these teaching resources also come from all over the world (not just Canada).

 

In what sense are you saying that IMG's don't measure up to CMG's or that there is a serious deficiency in performance?  The only real metric I know is the difference in pass rates between IMG's and CMG's for the MCCQE exams.  If it is this metric you are referring to there are a couple issues with it.  One thing is that the pass rates don't say anything about the actual scores IMG's have that actually make it into CaRMS and match into residency.  I would imagine that these would be relatively high similar to the higher USMLE scores for IMG's needed in the US compared to US grads.  

The second thing is that I agree there is a lot of variability in IMG's as they are a very very diverse group of people.  Whereas the CMG pass rate is based on all graduating/recently graduated medical students from Canadian medical schools with knowledge and preparation fresh on their minds (a fairly narrow sample size and group), the IMG group includes people who have recently graduated, graduated 20 years ago,, people practising, people out of practice for 5-10 years, people who train in a first world country with very similar medical systems and/or medical education models as Canada such as USDO schools, the UK, or Australia, along with people who trained from developing nations like Iran, Afghanistan, or Zimbabwe (I have no idea if Zimbabwe has a medical school).  Of course the pass rate will be vastly different since the statistic is not stratified and is generalized to such a diverse group of people with just about anyone with a medical degree being eligible to take the exams.  All the people I know from the UK and Australia had done extremely well on the MCC exams and as far as I know, are also excellent residents.

 

You mentioned that CSA's make up the majority of IMG's, just off the top of my head, don't they only make up around 25% of those applying in CaRMS?  However, I absolutely agree with you that IMG's will often gravitate towards urban centers.  All the evidence around the world has shown this and also the fact that ROS agreements for IMG's don't work other than as a temporary fix.  You are also right that the evidence has shown that recruiting medical students from under-served areas is the best way of filling the physician need in those areas.  In fact, in Australia (I'm a domestic medical student in Australia but have grown up in both countries), in addition to increasing the number of clinical schools in rural areas and recruiting for more rural students (who then aren't required to obtain the same academic standards as urban students to take into account their 'ruralness' and the lack of academic supports etc they have access to compared to urban students), there are specific rural bonded places for domestic students that have a ROS attached to them. I think this makes up like 1/3 the number of domestic places in a medical school actually.

 

In terms of CSA's, I would argue that the majority of them are not particularly wealthy upper class people coming from big family money and that they are actually drawn from largely the same socio-economic group as CMG's since many of them came from the same group of people applying to medical school in the first place.  As others have pointed out, there are many ways to fund CSA education and it can be quite do-able (though with a significant risk component obviously) from government loans, LOC, to parental contributions/second mortgages etc..  The tuition is actually quite similar to that of US medical schools anyways.  As you mentioned, medicine/CMG's already slant towards wealthier students with many that grew up in a medical family.  As others have also pointed out, barriers are already put in place against low-income students going to Canadian medical schools in everything from access to study resources such as prep-courses for the MCAT, tuition for an entire undergraduate degree, application fees for admissions tests, application fees to multiple medical schools, travel across the country for interviews, etc. etc.

 

Lastly in regards to the number of residency places, I absolutely do agree that these need to match the need and distribution of specialities required in the physician market for Canada.  I'm not sure if there are some good numbers/data yet on how saturated or maldistributed residency training places are yet and unfortunately, there isn't really a national strategy or body in place to track and control this but it is something that is needed.

 

You're right, IMGs/CSAs have to pass what CMGs do and then some... except graduating from an LMCC-accredited university. That's why I say it's a qualification in itself because the only other major point of distinction is in the pre-med stats, which are generally worse for CSAs than CMGs (and even then, some Canadian schools take individuals with somewhat lower stats than others, yet their students do just fine). It's the independent variable. That's not to say Canadian education is amazingly superior, just tailored to demands of a Canadian system. Contrary to your assertion, medicine isn't the same in every country, even advanced countries. There are different systems, patient populations, and standards of care. The average CMG wouldn't likely do as well in the UK as the average UK medical graduate. Bottom line is that even with all the protections and regulatory requirements to ensure we get the very best IMGs, if we started replacing IMGs with CMGs, statistically speaking we'll get better physicians.

 

MCCQE pass rates include a rate for those who have already matriculated to Canadian residency programs. The pass level is exactly the same (also the pass level for the USMLE is the same for all students, IMGs just need a higher score to get a residency). The rate for IMGs is significantly below that of CMGs. Heck the rate for first-time IMG test takers is lower than the rate for repeat CMG test takers. That's putting the best-of-the-best IMGs against arguably the lowest quality CMGs.

 

I'll repeat - the lower quality of IMGs is not my major concern, or a major component of why I argue to restrict IMG spots. If IMGs were exactly equivalent to CMGs, I'd still be making the same case. At a sheer minimum, the average IMG is certainly not superior to the average CMG. We're not gaining quality by accepting IMGs (and we may be reducing quality), so the other downsides to accepting IMGs to the extent that we do are not offset by gains in other factors.

 

That brings me to another item worth repeating - these policies apply on a group level, not on an individual level, so it's the group that matter, not the individuals. I don't doubt that you know students who studied in the UK or Australia who are good residents. I've said multiple times that there are excellent IMGs out there. Yet, for all the excellent ones, there are some not-so-excellent ones, as the available metrics show. The average IMG is, at a minimum, no better than the average CMG (and are likely worse), even if some IMGs are better than some CMGs. Reducing the number of IMG spots would eliminate poorer-quality IMGs as much as it would reduce the higher-quality IMGs - heck, if our system of picking good IMGs has any value, we'd lose more of the poorer-quality IMGs than the higher-quality IMGs.

 

CSAs make up fewer applicants, but are the majority of matriculants to IMG residency positions.

 

The CSA population is wealthier than the CMG population according to self-reported statistics. That follows directly from the constraints of going overseas, particularly to the "good" places you mention like the UK and Australia, which have international tuition costs well above those in Canada. There are individuals who are not well-off who do manage to go overseas for training, but they are the minority for the obvious reason that taking on $200-400k worth of debt for no better than a 50% chance of practicing medicine in Canada is not a worthwhile risk when your family income is the Canadian median of ~$75k per year. And yes, CMGs are also quite wealthy on the whole, but the first step to making a problem better is to not make it worse. CSAs make the problem of discrimination in access to the medical profession worse. More importantly, while medicals can, should, and in some cases do make changes to their admissions process to improve access to medicine for those of lower socioeconomic status, we have no such control over the CSA cohort.

 

There isn't a centralized set of statistics on the physician job market, but we're not exactly in the dark either. We need more family physicians and psychiatrists, with fewer orthopedic surgeons and neurosurgeons. We need fewer physicians in metropolitan areas like Toronto, Montreal and Vancouver, with more in rural areas or smaller cities. There are some fairly obvious changes we could make to our residency spots to adapt to those realities and, slowly, that is happening.

[indefatigable]

.

[ralk]

The analysis has been in-depth and precise. Aside from changing the distribution of residency positions (more FM for example), it might also make sense to also move the existing dedicated IMG streams to underserviced communities, like Northern Ontario. The IMGs will then have a realistic expectation of the positions that are available instead of believing that there are FM positions and jobs in Toronto. The one disadvantage I see is that perhaps UofT has more facilities available for training. On the other hand, there are probably numerous advantages in training in a similar environment where the jobs for the ROS are available.

As regards rural training, NOSM on many levels appears to have been successful. However it appears that sincere and dedicated individuals who wish to stay in the North are unable to do so, due to being raised in an urban environment. But it also seems that a number of nosm graduates may be more attracted to urban environments rather than staying the north, despite being from a northern or rural area (I recall seeing that UofT retains more for residency than nosm). Perhaps nosm should revise its policies to allow greater admission chances to those who have moved to the north, etc.. (an effective "IP" strategy).

 

There really isn't much to stop physicians or future physicians from practicing in Northern Ontario if they want to. Individuals from schools besides NOSM can do residency at NOSM (their positions are not horribly competitive) or finish their residency anywhere and get a job up north (there are many job postings). NOSM does consider those who have moved to a northern community in their acceptances, but they seem to require showing some longer-term dedication to the area, not a token move. A lot of individuals say they're willing to work up north if it means becoming a physician - and I don't doubt the sincerity of those assertions - but that's just their desire to be a physician overriding their desire to work where they want to. Once they become physicians... the true preferences show. NOSM's considerations for rural/remote individuals are pretty stringent for exactly that reason.

 

There are NOSM students who move away from the north after completing their schooling or residency. Then again, there are students from virtually every school who move away after completing their schooling or residency. Mobility of physicians and flexibility of choosing workplace preferences isn't a bad thing. The alternative is effectively ROS agreements for CMGs, which would work about as well as ROS agreements for IMGs (that is, not all that well). Besides, it's not individual physicians' decisions that matter, but collective physician decisions. NOSM students are far, far more likely to stay in the north long-term than non-NOSM students are to move to the north and practice. I agree that there are additional or better-tailored methods to encourage CMGs to practice in underserved communities, including putting more residency spots in those communities, as you suggest (I was reading a study that indicated where students do their residency is more important they where they do their MD for determining where they practice). However, the current regional requirements for MD admissions at many schools can be complementary to those approaches.

[GrumpyMoriarty]

There isn't a centralized set of statistics on the physician job market, but we're not exactly in the dark either. We need more family physicians and psychiatrists, with fewer orthopedic surgeons and neurosurgeons. We need fewer physicians in metropolitan areas like Toronto, Montreal and Vancouver, with more in rural areas or smaller cities. There are some fairly obvious changes we could make to our residency spots to adapt to those realities and, slowly, that is happening.

 

Not entirely true. Sometimes, there are physician shortages even in urban areas. For example, Vancouver is facing a serious shortage of family physicians right now as most well-established physicians have already a too-full client pool and are not accepting new patients. I've only just gotten into med school this year and people are already asking (half-seriously) if I would be A. come back to practice in BC and B. become a family doctor, as they really can't find any in Vancouver anymore. This may be isolated to Vancouver, which has a rapidly rising immigrant population who all want regular access to Canadian healthcare, but at least in our city we do not need fewer physicians. If anything, we probably need more, but the BC government isn't all too willing to dole out more $$ for that without raising taxes.

[ralk]

Not entirely true. Sometimes, there are physician shortages even in urban areas. For example, Vancouver is facing a serious shortage of family physicians right now as most well-established physicians have already a too-full client pool and are not accepting new patients. I've only just gotten into med school this year and people are already asking (half-seriously) if I would be A. come back to practice in BC and B. become a family doctor, as they really can't find any in Vancouver anymore. This may be isolated to Vancouver, which has a rapidly rising immigrant population who all want regular access to Canadian healthcare, but at least in our city we do not need fewer physicians. If anything, we probably need more, but the BC government isn't all too willing to dole out more $$ for that without raising taxes.

 

Fair enough, though I was making more of a broad generalization that still holds true. Vancouver could use more family physicians, I don't doubt that, but its overall physician levels are still very high. It's more of a maldistribution, with more than enough physicians but perhaps not the proper mix of physicians.

 

It's also hard to call what Vancouver's facing a "serious shortage" compared to the rest of Canada. Proportionally, Vancouver has the greatest number of Family Physicians in Canada. For example, London's region has about 60% as many physicians per population as the Vancouver region. 

 

Again, Canada could use more Family Physicians in general and what Vancouver is experiencing is part of that, but I stand by my statement - we need fewer physicians in Vancouver and more in the rest of Canada.

[older]

 

The CSA population is wealthier than the CMG population according to self-reported statistics. That follows directly from the constraints of going overseas, particularly to the "good" places you mention like the UK and Australia, which have international tuition costs well above those in Canada. There are individuals who are not well-off who do manage to go overseas for training, but they are the minority for the obvious reason that taking on $200-400k worth of debt for no better than a 50% chance of practicing medicine in Canada is not a worthwhile risk when your family income is the Canadian median of ~$75k per year. And yes, CMGs are also quite wealthy on the whole, but the first step to making a problem better is to not make it worse. CSAs make the problem of discrimination in access to the medical profession worse. More importantly, while medicals can, should, and in some cases do make changes to their admissions process to improve access to medicine for those of lower socioeconomic status, we have no such control over the CSA cohort.

 

 

You almost make it sound as if wealth was a crime. So what if CSAs (or rather, their parents)  are wealthy.  In what way "CSAs make the problem of discrimination in access to the medical profession worse"? 

 

CSAs pay for they own education, don't burden our medical education system, and so far, do not contribute to general "oversupply" of doctors in Canada because we don't have this problem (distribution is anothe matter).  While Canadian system could probably do better in balancing socio-economic disadvantages  when selecting applicants for med schools, there is no reason whatsoever to blame CSAs for that.

.

The reason why CSA attract  negative attitudes (even worse than  IMGs) is because there is a perception that they circumvent the system -  the circumvention being when "lesser" get education at their own costs versus "better" getting education funded by us the taxpayers. Even if we accept your argument that the average IMG or CSA is no better than the average CMG and likely worse, there are still educated professionals who have to meet the  same qualification criteria as CMGs to enter the profession. What's wrong with funding  own education while places in Canadian schools are filled by arguably more qualified applicants? CMGs don't contribute to "discrimination" (Canadian schools are free to discriminate or compensate as they wish) and do not cause lower quality of medical profession. At the end, every doctor has to qualify.

[ralk]

You almost make it sound as if wealth was a crime. So what if CSAs (or rather, their parents)  are wealthy.  In what way "CSAs make the problem of discrimination in access to the medical profession worse"? 

 

CSAs pay for they own education, don't burden our medical education system, and so far, do not contribute to general "oversupply" of doctors in Canada because we don't have this problem (distribution is anothe matter).  While Canadian system could probably do better in balancing socio-economic disadvantages  when selecting applicants for med schools, there is no reason whatsoever to blame CSAs for that.

.

The reason why CSA attract  negative attitudes (even worse than  IMGs) is because there is a perception that they circumvent the system -  the circumvention being when "lesser" get education at their own costs versus "better" getting education funded by us the taxpayers. Even if we accept your argument that the average IMG or CSA is no better than the average CMG and likely worse, there are still educated professionals who have to meet the  same qualification criteria as CMGs to enter the profession. What's wrong with funding  own education while places in Canadian schools are filled by arguably more qualified applicants? CMGs don't contribute to "discrimination" (Canadian schools are free to discriminate or compensate as they wish) and do not cause lower quality of medical profession. At the end, every doctor has to qualify.

 

To start, let me apologize for my inelegant phrasing and to correct it - CSAs themselves do not make the problem of discrimination in access to the medical profession worse, but a system that permits CSAs does. CSAs take advantage of that system and, in some cases, promote that system, but are not individually responsible for its existence. They're just trying to do the best they can with the pathways available to them, same as anyone, and I shouldn't have implied any fault on their part.

 

Ultimately, medicine as a profession is a zero-sum game. There are far more qualified people who want to be physicians than our country could afford to pay, even if we could somehow get them through med school and residency at zero cost. There has to be a restriction on the number of incoming physicians, because we're only willing to pay for so many. Contrary to your assertion, we are hitting those levels in Canada. There are numerous unemployed or underemployed physicians in specialties that are still accepting IMGs into residencies each year and governments are clamping down hard on medical costs. In that context, CSAs are not additional physicians, but are taking the place of CMGs we should be training here. If we cut the number of IMG spots to a minimum, we'd have to train more CMGs. That's not going to "burden our medical education system" - training an additional ~300 CMGs each year would be a drop in the bucket compared to our overall education or medical expenditures. Plus, we've managed that increase before - Ontario alone added that many spots in the last 15 years.

 

You brought up the distribution problem, so let's delve into that further. Underserviced communities are a major problem, even as we start to push the limits of the number of physicians we are willing to fund. The most likely physicians to serve these communities are those who are from those communities in the first place. That is, physicians who come from rural or remote areas and those who are of lower socioeconomic status. CSAs, being more likely than even CMGs to be wealthy or from large cities, are less likely to serve these communities in need. Switching from CSAs to CMGs would help address the distribution problem.

 

CSAs do circumvent the system that exists for most aspiring Canadian physicians and that circumvention has a lot to do with why I would prefer to move away from permitting significant numbers of CSAs to obtain residencies in Canada (and IMGs in general, because we can't legally separate the two). However, I don't advocate such a change as part of a morality play - a desire to punish CSAs for their circumvention or anything like that - but because in circumventing the system, there are negative consequences for the economy, for Canadian healthcare system, for the wider group of Canadian students who want to be physicians, and for Canadian patients. If we were to start significantly reducing the number of IMG residency spots, I would want that to be made clear years before it was put into place, ideally 4-5 years minimum, so that anyone who has already started their studies overseas won't have their chance to match back to Canada removed without warning. Again, the goal isn't to punish CSAs and I would be strongly against any move that changed things dramatically for CSAs hoping to match to Canada without notice.

[older]

Can you point out to data showing  that Canada has too many doctors?

 

I already conceded that geographical distribution is a problem. But this is mostly because most of CMGs do not want to go to rural areas. IMGs/CSAs may change the balance (one way or another) but only slightly. A better incentive system could help there.

 

I still can't see how CSAs have negative impact on economy, Canadian healthcare system, and Canadian patients. Withe regards to negative consequences to Canadian students who want to be physicians, CMGs are Canadians too, aren't they?  If you are concern about that, the knife should be out against foreign IMGs.

[ralk]

Can you point out to data showing  that Canada has too many doctors?

 

I already conceded that geographical distribution is a problem. But this is mostly because most of CMGs do not want to go to rural areas. IMGs/CSAs may change the balance (one way or another) but only slightly. A better incentive system could help there.

 

I still can't see how CSAs have negative impact on economy, Canadian healthcare system, and Canadian patients. Withe regards to negative consequences to Canadian students who want to be physicians, CMGs are Canadians too, aren't they?  If you are concern about that, the knife should be out against foreign IMGs.

 

Can you point out the data showing that Canada doesn't have too many doctors?

 

In any case, whether we have too many, not enough, or just the right amount of physicians is a moot point. For the most part, we only permit a certain number through the finite number of residency spots. We used to essentially give all these spots to CMGs. Then, we held the number of CMGs down and that led to an increasingly reliance on IMGs. After international (and domestic) pushback, we expanded CMG spots to reduce our reliance on IMGs. That has started to happen, slowly, but we still rely on IMGs for over 10% of new physicians. Long story short, the number of CMGs we train is directly related to the number of IMGs we accept. After decades of undersupplying CMGs and making up the difference with IMGs, I'd prefer to go back to supplying enough CMGs and that requires restricting IMGs.

 

We've tried about every incentive system possible to get people to work in underserved areas. Either they don't work, they're band-aids with inadequate long-term success, or they're ridiculously expensive. We want physicians who want to work in those locations and with those communities. Having people from those communities provides physicians with intrinsic motivation to work in those regions. We can (and do) pick those physicians with CMGs. We can't with CSAs, even if we wanted to. IMGs and CSAs are not the majority of new physicians, but they're not a small portion either. Even a small change in physician preferences would have a very meaningful impact on underserved communities. In addition, while replacing IMGs with CMGs wouldn't solve the distribution problem, no policy put forth would on its own - making the switch would at least get us closer.

 

How CSAs negatively impact the economy has been discussed in good detail earlier in the thread, so I won't repeat myself too much, but the gist of it is that the Canadian economy suffers from lost opportunity costs, misallocated human resources, lost productivity, not to mention the hundreds of thousands of dollars per student leaving Canada. It saves the government money in tuition costs, but the overall expense is much higher than what is saved. It's penny-wise, pound-foolish public policy. In terms of the healthcare system and patients, again, distribution is a key factor. I'll bring up the data that indicates IMGs may not be on par with CMGs as well. A cohort of physicians less likely to work where they're needed and possibly of lower quality does hurt the healthcare system and patients.

 

Lastly, for Canadian students who want to be physicans, it's true that CSAs are Canadians. But they're not necessarily the Canadians who would gain admission if we increased the number of CMG spots and cut off IMGs. Many wouldn't gain admission if CMG spots were expanded further. All applicants to residency programs - CMG or IMG - are Canadian citizens or permanent residents, so a Canadian gets that spot no matter what. But CSAs are getting a second shot at a medical career, a second shot that isn't open to many people who do not have the means to study abroad. That has huge negative consequences on the hundreds of deserving students who would have gained admissions here in Canada if we had more CMGs in place of those CSAs.

[older]

Yes, I can point the numbers, and let’s give them some context because over- or under-supply can be argued as relative.

 

After European Commission published 2014 Report on Health, UK widely lamented their poor ranking with regards to the number of physicians - 24th of 27 European countries - with 2.71 doctors per 1000 population (less than some poorest EU countries including Bulgaria, Estonia and Latvia). Health advocacy groups branded the situation “extremely worrying”.

 

Now Canada. OECD Health Statistics 2014 indicated that Canada has experienced a “substantial expansion” of its medical workforce since 2000, when it had a dismal 2.1 doctors per 1000 population. The report has only 2012 data from Canada showing 2.5 doctors per 1000 population, Canada thus remaining well below the OECD average of 3.2.

 

Lack of newer data is interesting considering all the publicity here, claiming that the number of doctors in Canada is rising faster than population. That may be true, but Canada remains shamefully behind, not only comparing to Europe but also to the most other developed countries including Australia, US, New Zealand, South Africa, and even Asian countries such as Mongolia and several others.

 

Still thinking that there are too many doctors in Canada ?