Residency backlog could triple for medical school grads, report warns

[la marzocco]

10 minutes ago, JohnGrisham said:

Im still not sure i follow.

Currently the usual order is this:

1. Round 1 CaRMs

2. Round 1 NRMP 

3. NRMP scramble

4. Round 2 CaRMS 

As long as you don't put programs you wouldn't want to attend on your ROL in Round 1 CaRMs, then the US NRMP match is open to you if you dont match in 1).

 

Have match day be the same for CaRMS and NRMP. And candidates who match both be given a chance to pick. If they pick NRMP they forfeit CaRMS. Let’s not speculate why they would - rep? US experience? Or perhaps for the very reason I spoke about earlier - FM match in CaRMS and matched ok to a competitive specialty down south.

Forfeited spots go into Round 2. Round 2/scramble should also take place on the same day. 

[JohnGrisham]

1 minute ago, la marzocco said:

Have match day be the same for CaRMS and NRMP. And candidates who match both be given a choice to pick. If they pick NRMP they forfeit CaRMS.

Round 2 should also take place on the same day. 

Essentially, i think what your saying is you want the ability to apply to Ortho and FM CaRMS round 1, and then also apply to Ortho in NRMP, and then have the choice of seeing if you match in NRMP or not, and then if you do, pick that over FM.

Again, ill say the solution is, don't apply FM in round 1,  because you will know before CaRMS ROL are due if you have a decent shot in the US NRMP match or not. 

CaRMS and NRMP are different systems, and they dont need to cater to this extremely small popln of students who want to keep 10 different options open.  Again, if you're applying NRMP, you will have a fairly good idea if you have a shot at matching or not - so your scenario wouldn't be very likely and only a handful of people would be in it. 

[indefatigable]

2 hours ago, JohnGrisham said:

Essentially, i think what your saying is you want the ability to apply to Ortho and FM CaRMS round 1, and then also apply to Ortho in NRMP, and then have the choice of seeing if you match in NRMP or not, and then if you do, pick that over FM.

Again, ill say the solution is, don't apply FM in round 1,  because you will know before CaRMS ROL are due if you have a decent shot in the US NRMP match or not. 

CaRMS and NRMP are different systems, and they dont need to cater to this extremely small popln of students who want to keep 10 different options open.  Again, if you're applying NRMP, you will have a fairly good idea if you have a shot at matching or not - so your scenario wouldn't be very likely and only a handful of people would be in it. 

There's no J-1 sponsoring of Ortho even.  A handful of SONs were given for Emergency and Derm - probably USMGs.  Most other surgery specialties (where matching problems are) don't even have accessible SONs.  The pan-Canadian matching ratios are going to barely budge - and no way would most US PDs would preferentially sponsor Visa CMGs over US citizens.  Plus SONs are basically "maxed out" for specialties like IM, pediatrics, radiology..    

[JohnGrisham]

20 minutes ago, marrakech said:

Plus I don't think the example is realistic for most CMGs.  It's hard to be competitive in both Canada and the US accounting for elective time, MLE scores, etc..  All of a sudden electives are not only getting divided up by specialty, but also by country.  

Yep, though apparently for some specialties, its really not necessary to do Away rotations..and away rotations are less common in the US if you aren't specifically going for a given region...compared to Canada where you'd ideally want to do some away electives. I.e. if you have strong USMLE scores, you can realistically get more than enough interviews to match to your chosen speciality.  This was not my understanding before, until i talked to a US colleague the other week. It somewhat makes sense, because of the vast number of programs in the US, and the more algorithmic approach to offering interviews.

[la marzocco]

34 minutes ago, JohnGrisham said:

Essentially, i think what your saying is you want the ability to apply to Ortho and FM CaRMS round 1, and then also apply to Ortho in NRMP, and then have the choice of seeing if you match in NRMP or not, and then if you do, pick that over FM.

Again, ill say the solution is, don't apply FM in round 1,  because you will know before CaRMS ROL are due if you have a decent shot in the US NRMP match or not. 

CaRMS and NRMP are different systems, and they dont need to cater to this extremely small popln of students who want to keep 10 different options open.  Again, if you're applying NRMP, you will have a fairly good idea if you have a shot at matching or not - so your scenario wouldn't be very likely and only a handful of people would be in it. 

Hmm fair point. Ok, then what I don't understand is in the AFMC summary doc on looking at timing, they called this point out as a disadvantage for CMGs? 

"Since the CaRMS match occurs prior to the US match each year, CMGs and USMGs will already have their Canadian matching decision before the US match takes place. This is an advantage for USMGs and a disadvantage for CMGs."

In 2017, 24 USMGs matched to CaRMS, and 7 CMGs matched to NRMP. There is an imbalance. What can be done? Or is this a fact of life that people will need to just make do?

[JohnGrisham]

10 minutes ago, la marzocco said:

Hmm fair point. Ok, then what I don't understand is in the AFMC summary doc on looking at timing, they called this point out as a disadvantage for CMGs? 

"Since the CaRMS match occurs prior to the US match each year, CMGs and USMGs will already have their Canadian matching decision before the US match takes place. This is an advantage for USMGs and a disadvantage for CMGs."

No idea. Im guessing they are alluding to the point of those 25 USMDs matching in Canada before they have the opportunity to match in the US, and thus "taking away CMG spots", whereas if NRMP was before CaRMS, they would be forced to not roll the dice and go the safer route of matching in the US.   Again, if the premise is that Canada is the first choice, having NRMP as your back up AFTER CaRMs has occurred is optimal. You cant have this process for CMGs, and then somehow do a different process for USMDs so they don't "steal our spots" etc. 

EDIT: Just looked at the document, and yes, that is the exact point they are trying to make. That USMDs have an unfair advantage because CaRMS is first.  Its just a product of the barrier to entry: Most Canadians don't take the USMLEs. Take them, and you open up a large number of spots, such that there would be no reason to go unmatched in FM, IM, Psych or Paediatrics..where 72% of CMGs match too in CaRMs anyways.

[rmorelan]

53 minutes ago, la marzocco said:

Also, should a delineation be made regarding CMGs and USMGs who are Canadian citizens? Not sure.

USMGs have a 50% match rate in CaRMS and take 25 spots yearly. 

I mean not sure how many people go down there(?) Is it a net balance, loss.....(?)

[JohnGrisham]

4 minutes ago, rmorelan said:

I mean not sure how many people go down there(?) Is it a net balance, loss.....(?)

[la marzocco]

5 minutes ago, rmorelan said:

I mean not sure how many people go down there(?) Is it a net balance, loss.....(?)

For 2017, 24 USMDs matched to Canadian residency spots, and only 7 CMGs matched to US residency spots. So I guess there is a net 17 deficit.

[rmorelan]

3 minutes ago, JohnGrisham said:

so the small net loss of err 10-15 or so.

I suppose ever bit counts - but I like the fact that we can go both ways. In the long run that is related to our ability to work in both countries usually (after we pass any associated exams). I really wouldn't want that to go away.

 

[indefatigable]

14 minutes ago, JohnGrisham said:

EDIT: Just looked at the document, and yes, that is the exact point they are trying to make. That USMDs have an unfair advantage because CaRMS is first.  Its just a product of the barrier to entry: Most Canadians don't take the USMLEs. Take them, and you open up a large number of spots, such that there would be no reason to go unmatched in FM, IM, Psych or Paediatrics..where 72% of CMGs match too in CaRMs anyways.

FM+Psych - yes, but both have supply > demand in CaRMS.  
IM and paediatrics -no since SONS are at max level (and demand > supply in CaRMS).  source 

[JohnGrisham]

Just now, marrakech said:

FM+Psych - yes, but both have supply > demand in CaRMS.  
IM and paediatrics -no since SONS are at max level (and demand > supply in CaRMS).  source 

In theory, CMGs could push out some IMGs for the J1, but H1B would definitely be on the table for the 2nd time around. I.e. you apply to IM/Paeds first time around, dont match and you re-apply following year to both CaRMS and NRMP.  

I'll have to look more into the timing of H1B processing and STEP 3 to see if its possible for a CMG to graduate and go straight into an H1B visa.  

[la marzocco]

3 minutes ago, JohnGrisham said:

In theory, CMGs could push out some IMGs for the J1, but H1B would definitely be on the table for the 2nd time around. I.e. you apply to IM/Paeds first time around, dont match and you re-apply following year to both CaRMS and NRMP.  

I'll have to look more into the timing of H1B processing and STEP 3 to see if its possible for a CMG to graduate and go straight into an H1B visa.  

https://www.mcgill.ca/medcareerplan/us-residencies/visa-issues - we were introduced to this in our career planning session. 

• You must have passed USMLE Step 3 prior to getting this visa, and you cannot write Step 3 until you have your MD diploma in hand. By the time you write the exam, get the score, and complete the visa paperwork process, it is usually September/October following the July 1 residency start date, so you are beginning residency late, and the programs to which you are applying have to be ready to delay your residency start date.
• An H1-B visa application is employer-sponsored, and many residency programs are unwilling to undertake the associated responsibility, expense, and inconvenience. You will usually be able to find out from a residency program’s website whether or not they are “H1-B supportive”, but if it is not evident, you will have to call the program office directly.

[indefatigable]

10 minutes ago, JohnGrisham said:

In theory, CMGs could push out some IMGs for the J1, but H1B would definitely be on the table for the 2nd time around. I.e. you apply to IM/Paeds first time around, dont match and you re-apply following year to both CaRMS and NRMP.  

I'll have to look more into the timing of H1B processing and STEP 3 to see if its possible for a CMG to graduate and go straight into an H1B visa.  

 

6 minutes ago, la marzocco said:

https://www.mcgill.ca/medcareerplan/us-residencies/visa-issues - we were introduced to this in our career planning session. 

• You must have passed USMLE Step 3 prior to getting this visa, and you cannot write Step 3 until you have your MD diploma in hand. By the time you write the exam, get the score, and complete the visa paperwork process, it is usually September/October following the July 1 residency start date, so you are beginning residency late, and the programs to which you are applying have to be ready to delay your residency start date.
• An H1-B visa application is employer-sponsored, and many residency programs are unwilling to undertake the associated responsibility, expense, and inconvenience. You will usually be able to find out from a residency program’s website whether or not they are “H1-B supportive”, but if it is not evident, you will have to call the program office directly.

Yeah.. kind of defeats the dual application CaRMS/NRMP though, since I'd wager that the H1-B sponsoring programs are not the competitive ones that are causing the problems in CaRMS.  

[JohnGrisham]

54 minutes ago, la marzocco said:

https://www.mcgill.ca/medcareerplan/us-residencies/visa-issues - we were introduced to this in our career planning session. 

• You must have passed USMLE Step 3 prior to getting this visa, and you cannot write Step 3 until you have your MD diploma in hand. By the time you write the exam, get the score, and complete the visa paperwork process, it is usually September/October following the July 1 residency start date, so you are beginning residency late, and the programs to which you are applying have to be ready to delay your residency start date.
• An H1-B visa application is employer-sponsored, and many residency programs are unwilling to undertake the associated responsibility, expense, and inconvenience. You will usually be able to find out from a residency program’s website whether or not they are “H1-B supportive”, but if it is not evident, you will have to call the program office directly.

Yep, so as expected, its realistically H1b is only going to be an option if you have to re-apply to CaRMS the following year around i.e. having a research year between graduation and hopefully starting residency somewhere in Canada or the US. 

Regardless, the # of CMGs who take USMLES and are eligible to apply to the US is a vastly small number. I think were splitting hairs here hah. 

The simple solution would be to make CMGs exempt from the SON caps, but that wont happen.

It's really all such a dynamic field these last few years: Not long ago there weren't even any caps on SONs, all you had to do was just make sure you matched. Then caps came around..and now caps have dropped such that the scenario of matching but not getting a SON has been realized in IM, and other specialties. 

Now with the ratio of residencies to CMGs getting even tighter, the backup option of doing residency in the US has decreased in likelihood also. 

It's really just further evidence that shows how disorganized the various stakeholders are, and that the gov't doesnt have much true sense in their workforce planning measures.


 

[indefatigable]

21 hours ago, JohnGrisham said:

Yep, so as expected, its realistically H1b is only going to be an option if you have to re-apply to CaRMS the following year around i.e. having a research year between graduation and hopefully starting residency somewhere in Canada or the US. 

Regardless, the # of CMGs who take USMLES and are eligible to apply to the US is a vastly small number. I think were splitting hairs here hah. 

The simple solution would be to make CMGs exempt from the SON caps, but that wont happen.

It's really all such a dynamic field these last few years: Not long ago there weren't even any caps on SONs, all you had to do was just make sure you matched. Then caps came around..and now caps have dropped such that the scenario of matching but not getting a SON has been realized in IM, and other specialties. 

Now with the ratio of residencies to CMGs getting even tighter, the backup option of doing residency in the US has decreased in likelihood also. 

It's really just further evidence that shows how disorganized the various stakeholders are, and that the gov't doesnt have much true sense in their workforce planning measures.


 

Yeah - caps are there there to limit providers, as you mentioned.  Last year there were ~520 SONs issued which seemed to be in line with previous years (mostly CSAs, I would suppose).  Assuming most return to Canada after their J-1, since it's difficult to stay in the US with that Visa (need to work at a VA, highly under-serviced region,...) that means there are about ~400-500 docs coming back to Canada, the equivalent of two large med schools. 

Moreover, they're clearly try to nudge people into some specialties.  The cap on FM is huge - going up to 500 alone, even though the limit on IM is maxed out at 180 and being decreased.  Some specialties like EM and Derm also have large caps ~80 altogether, even though they're also very difficult to match to in the US.  It's almost as if they're trying to take a passive approach to workforce management by using caps, kind of an odd approach.  

 

[Edict]

On 2/13/2018 at 11:45 AM, la marzocco said:

• Will Quebec be willing to loosen it's foothold on language requirements so that the 50-odd FM spots can be up for grabs? Unlikely?
• Streamline the timing of the Canadian and US matches to level the playing field? Since CaRMS happen before the NRMP, this is to the disadvantage of CMGs and to the advantage of USMGs. 
• Keep steaming for 2nd match - separate IMGs and CMGs?

- This won't help much but they should increase dermatology spots by a few considering there are plenty of jobs in the field still. 

- Canada would never do #2 (CaRMS happening before NRMP was not accidental). The brain drain would be absolutely devastating. Imagine Canada spending 270k or so to train a medical student just to see them go to the states. It would solve the residency problem so fast because 5-10% of CMGs would probably leave for the states. 

- I think as a whole we just need more spots, or cut med school enrollment unfortunately. 

 

[la marzocco]

8 minutes ago, Edict said:

- This won't help much but they should increase dermatology spots by a few considering there are plenty of jobs in the field still. 

- Canada would never do #2 (CaRMS happening before NRMP was not accidental). The brain drain would be absolutely devastating. Imagine Canada spending 270k or so to train a medical student just to see them go to the states. It would solve the residency problem so fast because 5-10% of CMGs would probably leave for the states. 

- I think as a whole we just need more spots, or cut med school enrollment unfortunately. 

Agreed on the paring back of the medical school enrolment as the most practical and efficacious way. Even at least to buy time for everyone to figure things out, especially if provincial residency funding is an issue. It simply does not make sense to churn our more grads than spots.

Derm is smart to have been so protective of its field. Job prospects are healthy in general. I doubt they would increase derm spots.

[medigeek]

23 hours ago, rmorelan said:

They already have been doing the latter point quite a bit already - not much slack left in many areas. 

How so?

[la marzocco]

23 hours ago, rmorelan said:

They already have been doing the latter point quite a bit already - not much slack left in many areas. 

 

10 minutes ago, medigeek said:

How so?

Yr	Dedicated IMG Q
2018	333
2017	338
2016	340
2015	337
2014	346
2013	348
2012	259
2011	234
2010	229

Good q.. just did a cursory look at dedicated IMG quota.. seems to be a reversion back to 2015 levels?

[medigeek]

6 hours ago, marrakech said:

Yeah - caps are there there to limit providers, as you mentioned.  Last year there were ~520 SONs issued which seemed to be in line with previous years (mostly CSAs, I would suppose).  Assuming most return to Canada after their J-1, since it's difficult to stay in the US with that Visa (need to work at a VA, highly under-serviced region,...) that means there are about ~400-500 docs coming back to Canada, the equivalent of two large med schools. 

Moreover, they're clearly try to nudge people into some specialties.  The cap on FM is huge - going up to 500 alone, even though the limit on IM is maxed out at 180 and being decreased.  Some specialties like EM and Derm also have large caps ~80 altogether, even though they're also very difficult to match to in the US.  It's almost as if they're trying to take a lazy person's path to workforce management by using caps, kind of an odd approach.  

 

You're over estimating the difficulty of staying in USA after a J1 and the difficulty of getting an H1. Getting a J1 waiver isn't difficult at all as there are a ton of underserved areas across USA and some of them aren't that undesirable by any measure. A big chunk of people on the J1 plan to indeed stay in USA. 

[medigeek]

5 minutes ago, la marzocco said:

 

Yr	Dedicated IMG Q
2018	333
2017	338
2016	340
2015	337
2014	346
2013	348
2012	259
2011	234
2010	229

Good q.. just did a cursory look at dedicated IMG quota.. seems to be a reversion back to 2015 levels?

Has there been a change in FM spots? I feel like IMGs either aim hard for FM or take their shot at some competitive specialty while the real focus is on USA.

[JohnGrisham]

7 hours ago, marrakech said:

Yeah - caps are there there to limit providers, as you mentioned.  Last year there were ~520 SONs issued which seemed to be in line with previous years (mostly CSAs, I would suppose).  Assuming most return to Canada after their J-1, since it's difficult to stay in the US with that Visa (need to work at a VA, highly under-serviced region,...) that means there are about ~400-500 docs coming back to Canada, the equivalent of two large med schools. 

Moreover, they're clearly try to nudge people into some specialties.  The cap on FM is huge - going up to 500 alone, even though the limit on IM is maxed out at 180 and being decreased.  Some specialties like EM and Derm also have large caps ~80 altogether, even though they're also very difficult to match to in the US.  It's almost as if they're trying to take a lazy person's path to workforce management by using caps, kind of an odd approach.  

 

More so they dont want excess specialists coming back and billing MSP.  Ironically, its relatively easier to match to a IM program then FM in the US because they have 2x the number of IM spots than FM.

Also, the SONs totals for each category are combined from the "need" each province submits. Last year BC provided the vast majority of the SON for FM, whereas Ontario put forth a need of ZERO for FM. Even though they know damn well many CSAs are from Ontario, and will come back to Ontario after US training.

If it wasnt for  BC,  there would be a lot of unmatched an unemployed IMGs. That said, the cuts to IM especially are going to hurt a lot of the CSAs, who traditionally can't get H1Bs like USMDs and USDOs without sitting out a year.

[medigeek]

22 minutes ago, JohnGrisham said:

More so they dont want excess specialists coming back and billing MSP.  Ironically, its relatively easier to match to a IM program then FM in the US because they have 2x the number of IM spots than FM.

Also, the SONs totals for each category are combined from the "need" each province submits. Last year BC provided the vast majority of the SON for FM, whereas Ontario put forth a need of ZERO for FM. Even though they know damn well many CSAs are from Ontario, and will come back to Ontario after US training.

If it wasnt for  BC,  there would be a lot of unmatched an unemployed IMGs. That said, the cuts to IM especially are going to hurt a lot of the CSAs, who traditionally can't get H1Bs like USMDs and USDOs without sitting out a year.

Not exactly true as it depends what type of candidate you are. FM spots will up with a lottt of foreign graduates whereas IM spots tend to fill up with higher scoring foreigners and more US graduates (MD/DO). Ultimately if you want to get into a decent program, you'll have better luck with FM than IM. 

[indefatigable]

4 hours ago, JohnGrisham said:

More so they dont want excess specialists coming back and billing MSP.  Ironically, its relatively easier to match to a IM program then FM in the US because they have 2x the number of IM spots than FM.

Also, the SONs totals for each category are combined from the "need" each province submits. Last year BC provided the vast majority of the SON for FM, whereas Ontario put forth a need of ZERO for FM. Even though they know damn well many CSAs are from Ontario, and will come back to Ontario after US training.

If it wasnt for  BC,  there would be a lot of unmatched an unemployed IMGs. That said, the cuts to IM especially are going to hurt a lot of the CSAs, who traditionally can't get H1Bs like USMDs and USDOs without sitting out a year.

Interesting - CSAs definitely do have BC to thank.  If the quota of Emerg and Derm filled up though, it would certainly make a dent in the supply of those specialists.