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Realignment of Doctor's Income


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3 hours ago, LittleDaisy said:

They are cutting down revenues for FHO & FHT GPs as well. I received a few emails from OMA on Friday. I hope that it won't go through, it will further decrease the interest in Family Medicine when we know there is a high need. 

Let's just say this is a mess all around. Every field impacted is worried that they won't get enough or get as high a caliber of student moving forward. I know radiology is extremely worried about that for sure. 

I think part of why this is so annoying is it is hard to see where exactly the bottom is. 

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45 minutes ago, rmorelan said:

Let's just say this is a mess all around. Every field impacted is worried that they won't get enough or get as high a caliber of student moving forward. I know radiology is extremely worried about that for sure. 

I think part of why this is so annoying is it is hard to see where exactly the bottom is. 

I think that for family physicians, they are cutting down revenues, rather than saying freezing fees for the next few years, which is worrisome. As the cost of living continues to rise, I don't understand the rationale of decreasing enrollment fee for new patients (which is a major proportion of FHO physicians) , getting rid of preventative bonuses for Pap smear, FOBT, influenza (which are very important for preventative health) and make some out-of-basket codes---> in-basket ( which you are getting paid 15%) . Also, they ask for at least > 6 GPs for new FHO & FHT, which could be a problem in small rural community where they already have trouble retaining physicians. 

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2 hours ago, shematoma said:

If I had to speculate, one reason compensation in Canada won't drop much is the potential for doctors to relocate to the US. Most doctors wouldn't be willing to do this (politics, family, having to take USMLE, etc. and FM need a 3rd year of residency), but all it takes is a small number before the healthcare system starts feeling the pinch.

It turns out that FM in Canada tends to make more (at least in AB) with fewer headaches, so I wouldn't bank on that. If you really wanted to move, the 3rd year isn't really a huge concern. If you have the USMLEs written, you can get an H1B to work as a physician. It's not that difficult to then get board certified in FM:

Quote

Physicians who have passed the College of Family Physicians of Canada (CFPC) Certification Examination in Family Medicine may apply to sit for the ABFM Family Medicine Certification Examination, if they:

  • are certified by exam and a member in good standing of the College of Family Physicians of Canada at the time of application;
  • have satisfactorily completed two years of post-graduate residency training in family medicine accredited by the College of Family Physicians of Canada;
  • have been a resident of the United States for at least six (6) months;
  • hold a valid and unrestricted license to practice medicine in the United States; and,
  • are actively involved in Family Medicine in the United States for at least six (6) months

Point 1-2 are a given. Point 3 follows from point 5. Point 4 basically means you work in a state which grants an unrestricted license to practice medicine to those who have completed at least a PGY1. Once you have a license, of course, it's probably not going to be that hard to get a job in an FM clinic. I personally wouldn't want to make the move, but, again, that's really all the bargaining power that you have in a single-payer system.

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@insominas

Also to note, i think* maybe not 100% sure, but depending on the state, you can practice with the MCCQEs as your "board exams" and not need to do USMLEs. You need to get CCFP in Canada, do a +1 year, then get ABFM boards, and then you in theory could get TN visa jobs or J1s to work in the US as a FM doc.

This is from anecdotal discussion though, no real source and could be completely wrong.

But yeah, at least from those in my social circle, FM in Canada tends to pay more than in the US without a lot of the associated headaches and big corporate conglomerates and HMOs.

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1 minute ago, JohnGrisham said:

@insominas

Also to note, i think* maybe not 100% sure, but depending on the state, you can practice with the MCCQEs as your "board exams" and not need to do USMLEs. You need to get CCFP in Canada, do a +1 year, then get ABFM boards, and then you in theory could get TN visa jobs or J1s to work in the US as a FM doc.

This is from anecdotal discussion though, no real source and could be completely wrong.

But yeah, at least from those in my social circle, FM in Canada tends to pay more than in the US without a lot of the associated headaches and big corporate conglomerates and HMOs.

There are some place doing there where you practice without the USMLEs as well. I happen to be in one such state right now actually. 

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5 minutes ago, rmorelan said:

There are some place doing there where you practice without the USMLEs as well. I happen to be in one such state right now actually. 

I'm guessing that one would at least have to write their American boards, at the very least, if they do not have their USMLEs? Would they just apply for a practice license from the provincial medical association with the LMCC Part I & II? 

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30 minutes ago, insomnias said:

It turns out that FM in Canada tends to make more (at least in AB) with fewer headaches, so I wouldn't bank on that. If you really wanted to move, the 3rd year isn't really a huge concern. If you have the USMLEs written, you can get an H1B to work as a physician. It's not that difficult to then get board certified in FM:

Point 1-2 are a given. Point 3 follows from point 5. Point 4 basically means you work in a state which grants an unrestricted license to practice medicine to those who have completed at least a PGY1. Once you have a license, of course, it's probably not going to be that hard to get a job in an FM clinic. I personally wouldn't want to make the move, but, again, that's really all the bargaining power that you have in a single-payer system.

What would most people do the +1 in? It has to be a CCFP approved R3, or could be done in the USA as well - but in what form would that be? Most of us who'd move to the USA want to at least be board certified rather than practicing with only PGY1 as this would be needed to get paid by insurance. It would seem wise to do all 3 steps of the USMLE just to not be restricted from practicing in any particular state. It's a small price to pay.

Also, the latest Medscape compensation report shows FM average in the US is now $219K, which works out to about C$286K. Assuming that's net income after overhead (if applicable - many FMs in the USA are employed), that's not bad. It's also been steadily rising the last few years.

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36 minutes ago, ArchEnemy said:

I'm guessing that one would at least have to write their American boards, at the very least, if they do not have their USMLEs? Would they just apply for a practice license from the provincial medical association with the LMCC Part I & II? 

oh yeah you need the board exam - kind of makes sense though. I mean we are both under the same accreditation board, and no one is going to care about the general medicine stuff when you are neck deep in your specialty - at least in the real world. 

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14 hours ago, NLengr said:

I've never seen a breakdown of numbers, and I know pilot loses to commercial operations are a big deal for the RCAF but I wonder if most of those losses are multi engine pilots (Hercs, Polaris, CP-140 etc) and helicopters vs fighter pilots. 

I mean, non fighter pilots would have a more similar civilian flying job. It's easy to imagine how mind numbing flying an Air Canada 737 would be after years of flying a CF-18. 

In the States it would be less of an issue to leave fighters because the Air National Guard gives you an opportunity to fly commercial and continue to fly fighters part time.

I had the same thought about switching.  I can't find the Canadian numbers easily - I did come across with a quick google search two "comparators": Finland and the US.  

Fully 70% of Finish jet fighter pilots want to leave to fly commercial aircraft b/c of roughly double pay (link)

The US jet fighter pilots have been offered retention bonuses to stay - with only about 50% taking (link).  It costs about 10 mill to train one of those pilots - but they seem to do about 10 years of active duty before they switch.  

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4 hours ago, shematoma said:

If I had to speculate, one reason compensation in Canada won't drop much is the potential for doctors to relocate to the US. Most doctors wouldn't be willing to do this (politics, family, having to take USMLE, etc. and FM need a 3rd year of residency), but all it takes is a small number before the healthcare system starts feeling the pinch.

Yes and no I'd say.  About 20-25% of practicing physicians in AB, BC and ON are foreign-trained (outside of CAN/US).  Sure some of that is historical, but every Canadian IMG who goes through US residency training on a J-1 visa must return to Canada (in addition to the relatively small IMG quota in CaRMS)(link).  Sure there are a few ways around this, but Canadian practice is attractive to many and most will be coming back in primary care.  In 2014 there were roughly 800 non-returning CSAs applying to CaRMS - by now it could be about 1500 (link).  It's hard to tell the number that matches, but it could definitely make a significant impact in the work force.  For comparison, QC has only about 1/10 foreign-trained physicians.  Bottom line - it's not only CMGs that determine the number of practicing physicians in Canada and I would say especially in primary care .      

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2 hours ago, JohnGrisham said:

@insominas

Also to note, i think* maybe not 100% sure, but depending on the state, you can practice with the MCCQEs as your "board exams" and not need to do USMLEs. You need to get CCFP in Canada, do a +1 year, then get ABFM boards, and then you in theory could get TN visa jobs or J1s to work in the US as a FM doc.

This is from anecdotal discussion though, no real source and could be completely wrong.

But yeah, at least from those in my social circle, FM in Canada tends to pay more than in the US without a lot of the associated headaches and big corporate conglomerates and HMOs.

Federally, you need the USMLEs to get an H1B but not a green card or J1. Only the H1B/green card actually allow you to work as an independent physician; TN is only good for non-practising roles whereas J1 is an educational (ie residency/fellowship) visa

1 hour ago, shematoma said:

What would most people do the +1 in? It has to be a CCFP approved R3, or could be done in the USA as well - but in what form would that be? Most of us who'd move to the USA want to at least be board certified rather than practicing with only PGY1 as this would be needed to get paid by insurance. It would seem wise to do all 3 steps of the USMLE just to not be restricted from practicing in any particular state. It's a small price to pay.

Also, the latest Medscape compensation report shows FM average in the US is now $219K, which works out to about C$286K. Assuming that's net income after overhead (if applicable - many FMs in the USA are employed), that's not bad. It's also been steadily rising the last few years.

You misunderstand. The R1 allows you to get an independent license to practice. Thus you can work as a non-certified "family doctor" for 6 months, challenge the US boards based on having CCFP, and get board certified in FM. No +1 required if you go that way.

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3 hours ago, insomnias said:

Federally, you need the USMLEs to get an H1B but not a green card or J1. Only the H1B/green card actually allow you to work as an independent physician; TN is only good for non-practising roles whereas J1 is an educational (ie residency/fellowship) visa

You misunderstand. The R1 allows you to get an independent license to practice. Thus you can work as a non-certified "family doctor" for 6 months, challenge the US boards based on having CCFP, and get board certified in FM. No +1 required if you go that way.

Ah yes, sorry been a long day defintiely didnt have my head on straight with the visa's.

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6 hours ago, insomnias said:

Federally, you need the USMLEs to get an H1B but not a green card or J1. Only the H1B/green card actually allow you to work as an independent physician; TN is only good for non-practising roles whereas J1 is an educational (ie residency/fellowship) visa

You misunderstand. The R1 allows you to get an independent license to practice. Thus you can work as a non-certified "family doctor" for 6 months, challenge the US boards based on having CCFP, and get board certified in FM. No +1 required if you go that way.

Interesting. Do you know of people who've gone this route? Is it possible to find work as a non certified FM physician? I assume that merely prescribing medical marijuana isn't gonna cut it :)

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I would not necessarily be against some sort of required "service" period but it presupposes changes to the postgraduate training system. If we had a common "internship" like system with 1-2 years of broad training, to be followed with a period of service in a GP/urgent care/community emerg setting that might make sense. Not all that likely, though...

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On 10/21/2018 at 3:46 PM, rmorelan said:

Thought this might lead to some discussion on the forum - I have been saying for ages on the forum that the landscape of doctor's income will change at some point and the high paying fields - of course my specialty of radiology is of course one - will be reduced. While today the OMA has acted on that outside in fact of the government directly - and will be reducing the fees of various fields to increase the income of others internally. 

I am still learning the details but if I am understanding this:

The groups immediately impacted will include:

Opthalmology
Radiology
Cardiology
Gastroenterology

The groups next on the block if there are no fee increases of 1.5% or higher include:

Radiation Oncology 
Anesthesiology
Clinical Immunology 
Nephrology
Lab Medicine
Vascular Surgery
ENT
Endocrine
Nuclear Medicine 
Urology
General surgery
Rheumatology

The groups who will see their fees remain flat for the next decade based on the plan, if no new money is injected include:

Dermatology
Pediatrics
Medical Oncology
Orthopedic Surgery
ER
Neurology

which is most of the fields outside of family medicine and psychology (which are relatively lower paying). This move will I am sure have an impact on some people's specialty choices, and since some of the discussions on the forum revolve around income I thought I will mention all this - the idea long term is basically it is that roughly speaking an hours work will be worth similar values. It will also have big impacts I am sure on the hiring landscape - any one in a field being cut won't be looking to add any new warm bodies to the mix any time soon. Traditionally that means it will be hard to find work. I assume as well it will have a ripple effect on other provinces as well. 

Which fields, if any, will be getting increases?

If new money is injected into the system, will emerg, pediatrics, neurology, etc. actually be the first to receive increases?

What is the planned fate of unlisted specialties such as physiatry, neurosurgery, hematology, etc?

How significant will the cuts to ophtho, rads, cards, and GI be?

I am surprised to see that they may be going after immunology, endo, and ENT. 

Ideally, all physicians would remain under the same representative organization. Personally, however, if I belonged to any of the specialties on the chopping block, this behaviour from the OMA would be intolerable when they are supposed to be protecting my interests. I don't blame them for wanting to split away and forming a specialists association, although I cannot see why pediatrics, emerg, etc. would want to join. 

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6 hours ago, Let'sGo1990 said:

 Ideally, all physicians would remain under the same representative organization. Personally, however, if I belonged to any of the specialties on the chopping block, this behaviour from the OMA would be intolerable when they are supposed to be protecting my interests. I don't blame them for wanting to split away and forming a specialists association, although I cannot see why pediatrics, emerg, etc. would want to join. 

That’s one of the difficulties of the situation. As someone in one of the lower paid specialties (psychiatry, a 0.86 based on CANDI score) why would I want to support a group that I suspect wants to maintain the status quo of having such significant disparities in pay between different medical specialties?  I certainly wouldn’t feel that a specialty interest group would see the interests of my specialty as being a priority despite the fact that we are one of the largest based on numbers.  The group being formed by a radiologist makes me suspect the intentions of this right from the get-go. 

This current malignant environment has existed between the MOHLTC and Ontario physicians for at least the past 8 years (I was a pre-clerk when our previous contract ended and things started to escalate in ugliness between the OMA and MOHLTC). It’s been very difficult to have any meaningful decision about rebalancing/realitivity for this exact reason, when the OMA finally started to talk about making concrete changes based on realitivity, it caused splinters within groups of doctors which now weakens our overall bargining power. It’s also an understanding of mine that the grassroots organization Concerned Doctors Ontario was largely funded by and driven by the high paid specialties.

Unfortunately at the end of the day money usually talks louder than everything else. We like to consider our physicians at large to be much more altruistic than we are. Especially coming from a speciality which is often treated with hostility and disrespect (at least at academic centres, but I also suspect in the community setting to a lesser degree) from other medical specialties, it makes it a bit harder to find a lot of sympathy for some of these groups being targeted by realitivity changes. I really don’t feel that the current remuneration is reflective of the hours worked and responsibility that some specialties have. One group in particular that I do feel bad for is pediatrics. IMO they are certainly undervalued financially (compared to other physicians at least) for the responsibility that they carry. 

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On 10/23/2018 at 8:32 PM, A-Stark said:

I would not necessarily be against some sort of required "service" period but it presupposes changes to the postgraduate training system. If we had a common "internship" like system with 1-2 years of broad training, to be followed with a period of service in a GP/urgent care/community emerg setting that might make sense. Not all that likely, though...

The problem would be that's even more time until you get to whatever specialty you want. Most people are already in their early 30's when they finish specialty residency (then add on a couple years for potential fellowships). 

I think to see that work you would need to shorten training somewhere else. Maybe get rid of the undergrad degree requirements and go back to letting people in to med school after 2 years of university. 

Like you said, that is a lot of changes to the system. 

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2 hours ago, BigM said:

it makes it a bit harder to find a lot of sympathy for some of these groups being targeted by realitivity changes. I really don’t feel that the current remuneration is reflective of the hours worked and responsibility that some specialties have. One group in particular that I do feel bad for is pediatrics. IMO they are certainly undervalued financially (compared to other physicians at least) for the responsibility that they carry. 

The problem is once the government has cut the obvious targets, they aren't going to stop there. Your specialty will eventually be on the chopping block too. They vilify all physicians as overpaid fat cats, they dont distinguish. Either does the public. 

 

Make no mistake, if the government could pay you 60k a year like the average civil servant, they would. Politicians do not value your work. They just care about reducing spending on healthcare no matter what the effects on the system. 

 

If we don't all stand together in this, we will be picked off one by one and have nobody but ourselves to blame. 

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51 minutes ago, NLengr said:

The problem is once the government has cut the obvious targets, they aren't going to stop there. Your specialty will eventually be on the chopping block too. They vilify all physicians as overpaid fat cats, they dont distinguish. Either does the public. 

 

Make no mistake, if the government could pay you 60k a year like the average civil servant, they would. Politicians do not value your work. They just care about reducing spending on healthcare no matter what the effects on the system. 

 

If we don't all stand together in this, we will be picked off one by one and have nobody but ourselves to blame. 

truth is we really don't know where the bottom is to all of this - and that is the most worrying part about it. Every time there is a funding short fall basically doctors are an obvious target. We have had roughly 10 years of cuts, and now we have roughly signed up for 10 years more. There is not particular reason to think based on all of this that we would be better at arguing all of this in 10 years time either ha. There is a lot of doom and gloom floating around, burn out rates are really high, and people are just feeling squeezed. 

A lot of the discussion is also tends to ignore the number of hours some of these specialists do. Cardiology works crazy hours both in numbers and in timing - makes sense they would earn more. Even on an hour by hour basis some of the jobs in medicine are just more work than some of the other hours - none of them are easy and require no skill mind you, but I am not sure a 12 hour brain surgery should be charging exactly the same per hour as every other type of medicine either. Many of the fields getting cut - ha radiology is one of them - shot themselves in the foot by responding to the cuts by working increasingly long hours at all hours to compensate to the point of implosion. 

and to be clear with all of this it isn't like any of the other fields are actually getting raises. They are taking about meager 1.5% increases here which are below inflation. That means every single field would actually be getting most likely cuts over the next 10 years but some are getting cut worse than others. This is also just the OMA response - the BEST case scenario basically as the government will as other pointed out very likely will go lower than this. 

What will the effect be? Hard to full say. Most physicians don't want to move etc or cannot. Some as usual with this will retire anyway as they may feel they don't want to play the game as  it where. Some will choose to go to other provinces - which probably will also eventually have similar cuts etc - and small group will as always go to the US. What is weird about that personally is that I never considered going to the US as Canada is my home. Now that I am here I am being targeted  (as many of us are) for positions here. It is strange to see there are actually other options, and instead of being treated like a cost burden having people treating you like you are a highly trained, valuable and in demand professional. You can see why some people do chose to leave. 

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3 hours ago, rmorelan said:

 

A lot of the discussion is also tends to ignore the number of hours some of these specialists do. Cardiology works crazy hours both in numbers and in timing - makes sense they would earn more. Even on an hour by hour basis some of the jobs in medicine are just more work than some of the other hours - none of them are easy and require no skill mind you, but I am not sure a 12 hour brain surgery should be charging exactly the same per hour as every other type of medicine either. 

I was gonna bring this up earlier but figured it would stir the pot too much. 

I don't agree that all specialties should be earning the same. Some just are higher stress, or more work, than average. Some are both. 

For example, imo, there is no way vascular surgery should get paid the same as rheumatology, endo, nuclear medicine, rad once, public health etc. Vascular surgery is crazy busy, full of the sickest patients and performs extremely high stress surgeries. 

That is not to say I don't value all specialties. I think everyone e has a role and is valuable to the patients when they are needed. 

Now do I think some specialties should get more money for ffs work? Yes. Just like I think some are overpaid for ffs work. But I don't buy into the whole "everyone should earn the same amount" arguement.

For the record, I'm pretty happy with my pay. I'm not in the best paid surgical specialty, but I'm also not at the bottom. 

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7 hours ago, bloh said:

Are we really going through this again? Can't someone bring up the 90s where there was a huge drain to the states?

There definitely has to be some sort of equalization between sections but  cutting everyone is just going to fuck shit up.

At least anecdotally, i think med students of this generations and residents are less inclined to take USMLEs and jump through hoops to go to the US. Its objectively a lot harder nowadays to just get up and move to the US. Not unmanageable, but definitely logistically harder than before.  

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54 minutes ago, JohnGrisham said:

At least anecdotally, i think med students of this generations and residents are less inclined to take USMLEs and jump through hoops to go to the US. Its objectively a lot harder nowadays to just get up and move to the US. Not unmanageable, but definitely logistically harder than before.  

Plus we haven't had any motivation to do so for a long time relatively speaking ha. It is a big move after all. 

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12 hours ago, rmorelan said:

truth is we really don't know where the bottom is to all of this - and that is the most worrying part about it. Every time there is a funding short fall basically doctors are an obvious target. We have had roughly 10 years of cuts, and now we have roughly signed up for 10 years more. There is not particular reason to think based on all of this that we would be better at arguing all of this in 10 years time either ha. There is a lot of doom and gloom floating around, burn out rates are really high, and people are just feeling squeezed. 

A lot of the discussion is also tends to ignore the number of hours some of these specialists do. Cardiology works crazy hours both in numbers and in timing - makes sense they would earn more. Even on an hour by hour basis some of the jobs in medicine are just more work than some of the other hours - none of them are easy and require no skill mind you, but I am not sure a 12 hour brain surgery should be charging exactly the same per hour as every other type of medicine either. Many of the fields getting cut - ha radiology is one of them - shot themselves in the foot by responding to the cuts by working increasingly long hours at all hours to compensate to the point of implosion. 

and to be clear with all of this it isn't like any of the other fields are actually getting raises. They are taking about meager 1.5% increases here which are below inflation. That means every single field would actually be getting most likely cuts over the next 10 years but some are getting cut worse than others. This is also just the OMA response - the BEST case scenario basically as the government will as other pointed out very likely will go lower than this. 

What will the effect be? Hard to full say. Most physicians don't want to move etc or cannot. Some as usual with this will retire anyway as they may feel they don't want to play the game as  it where. Some will choose to go to other provinces - which probably will also eventually have similar cuts etc - and small group will as always go to the US. What is weird about that personally is that I never considered going to the US as Canada is my home. Now that I am here I am being targeted  (as many of us are) for positions here. It is strange to see there are actually other options, and instead of being treated like a cost burden having people treating you like you are a highly trained, valuable and in demand professional. You can see why some people do chose to leave. 

I have never considered moving to the US during my medical school training. However, it's talks about cuts and the nasty politics displayed by the (previous) government that have convinced me to take the USMLEs while I still have some residual knowledge about FOOSH or menstrual cycles. I would imagine that this will be the biggest hurdle for most practising physicians though.

I would rather work in an environment where by skills and knowledge are valued.

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3 hours ago, JohnGrisham said:

At least anecdotally, i think med students of this generations and residents are less inclined to take USMLEs and jump through hoops to go to the US. Its objectively a lot harder nowadays to just get up and move to the US. Not unmanageable, but definitely logistically harder than before.  

In roughly 2 months of med school, I've heard the words "take the USMLEs" from residents/staff at least thrice, including today. We're definitely aware of our options and thinking about what might be necessary to do it. Considering the number of specialties that now require fellowships to get jobs, many of which end up being done in the US, I think the number of CMGs taking the USMLEs will only increase

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