(Neurosurg) Realistic advice about job prospects

[MasterDoc]

On 2/15/2021 at 10:30 AM, Jack Marcos said:

Unfortunately, no. Any individuals who completed training after 1997 in Canada can no longer become certified in the United States, doesn’t matter how many fellowships you do. http://www.neurosurgeryschools.com/faqs/index.htm
 

You can still practice in the United States though.

Is there a list of residencies which are not eligible for board certification in the US? I know neurosurg, ENT and FM are it, but are there any other ones?

[jnuts]

On 2/17/2021 at 2:52 PM, MasterDoc said:

Is there a list of residencies which are not eligible for board certification in the US? I know neurosurg, ENT and FM are it, but are there any other ones?

I've never seen a list. You need to check Board-by-Board.

[blah1234]

On 2/17/2021 at 2:52 PM, MasterDoc said:

Is there a list of residencies which are not eligible for board certification in the US? I know neurosurg, ENT and FM are it, but are there any other ones?

I've also never seen a list and found out mostly through word of mouth. I feel like this is almost intentional as you don't want to inform students what their options are so they stick around in Canada in high-need fields.

Could be an interesting initiative for CFMS as you just need a couple of students to do some phone calls and website research to compile a spreadsheet for medical students to get informed about future cross-border employment issues.

[MasterDoc]

2 hours ago, blah1234 said:

I feel like this is almost intentional as you don't want to inform students what their options are so they stick around in Canada in high-need fields.

Most docs that jump the border I always assumed it was because of the lack of employment opportunities of specialists in Canada. So, the argument of needing to keep doctors here because they are "needed" makes no sense if the government can't provide a job for them.

[blah1234]

57 minutes ago, MasterDoc said:

Most docs that jump the border I always assumed it was because of the lack of employment opportunities of specialists in Canada. So, the argument of needing to keep doctors here because they are "needed" makes no sense if the government can't provide a job for them.

The government doesn't care if there aren't jobs available they just care if there is a supply which can only help them deliver patient care. My neurosurgery colleague told me that a big reason why the curriculum doesn't match up was because there was an effort to prevent a brain drain to the US a while back. I don't know if this is true as this is just their hearsay.

While there may not be a full staff position there are usually random locums that people can secure which still provides the end goal of patient care which the government cares about without any consideration for the needs of new graduates.
 

[jnuts]

8 hours ago, blah1234 said:

The government doesn't care if there aren't jobs available they just care if there is a supply which can only help them deliver patient care. My neurosurgery colleague told me that a big reason why the curriculum doesn't match up was because there was an effort to prevent a brain drain to the US a while back. I don't know if this is true as this is just their hearsay.

While there may not be a full staff position there are usually random locums that people can secure which still provides the end goal of patient care which the government cares about without any consideration for the needs of new graduates.
 

Seems a little egotistical on the Canadian side.  The decision is ultimately up to the American Boards to allow or not allow Canadian applicants. The Americans set and revise their criteria for acceptable training all the time without consulting Canadians.  If anything, I think the restrictions are a protectionist pressure from the American side to prevent possible flooding of their market (if they think about Canadians at all).

There's other evidence of this in the NAFTA agreement (or whatever it's called now).  Most Canadian professionals, including lawyers, nurses, and RTs can just show up at the boarder with a job offer and get a TN visa on the spot. There's a specific carve out that prevents Canadian medical doctors from accessing TNs so they have to get the far more restricted and onerous H1bs or J1s. Thank the AMA for that one. 

The more interesting question is why do any of the American Boards allow Canadians to sit their exams? 

https://travel.state.gov/content/travel/en/us-visas/employment/visas-canadian-mexican-nafta-professional-workers.html

[blah1234]

15 minutes ago, jnuts said:

Seems a little egotistical on the Canadian side.  The decision is ultimately up to the American Boards to allow or not allow Canadian applicants. The Americans set and revise their criteria for acceptable training all the time without consulting Canadians.  If anything, I think the restrictions are a protectionist pressure from the American side to prevent possible flooding of their market (if they think about Canadians at all).

There's other evidence of this in the NAFTA agreement (or whatever it's called now).  Most Canadian professionals, including lawyers, nurses, and RTs can just show up at the boarder with a job offer and get a TN visa on the spot. There's a specific carve out that prevents Canadian medical doctors from accessing TNs so they have to get the far more restricted and onerous H1bs or J1s. Thank the AMA for that one. 

The more interesting question is why do any of the American Boards allow Canadians to sit their exams? 

https://travel.state.gov/content/travel/en/us-visas/employment/visas-canadian-mexican-nafta-professional-workers.html

Perhaps there's US pressure to prevent the influx of Canadians but I honestly find that a little hard to believe as well as the number of specialists we produce is not that large in comparison to their existing training pipeline. I think the job markets for things like family medicine and neurosurgery are pretty good in the US (as neurosurg has more opportunities in the community compared to Canada).

I honestly have no idea what the policy logic is as I'm assuming my colleagues learned their history facts from their professors who were probably in the know. That combined with my pessimism with how the government increasingly wants to manage us as resources is probably why I came to that conclusion.

You might be right that they don't think about us at all. Given that medical research and knowledge are largely focused around US centres (due to funding) I would always assume that our training would parallel theirs given the similarities. It just seems really odd that we wouldn't adapt our curriculum to match unless there was some other pressure involved. But maybe that's just misplaced paranoia.

[shikimate]

You made a good point about the TN visa. You can still go to US on a J1 and try to work in a rural area to get waiver, or try to get institutional H1B sponsorship (usually limited to large academic centers).

Anecdotally I know of ENT people working in US (large cancer center) without US board certification, on an institution sponsored visa (not sure what type). I am not sure if board certification affects billing for these people or not.  

So overall getting medical license in US is easy, but board certification varies by specialty. For example small rural places in US desperate for doctors will accept someone without FM boards (eg. a resident with 1-2 years experience in IM/FM, etc). Again their employment model is very different, so I guess that could open certain doors and close other doors.

 

[blah1234]

2 minutes ago, shikimate said:

You made a good point about the TN visa. You can still go to US on a J1 and try to work in a rural area to get waiver, or try to get institutional H1B sponsorship (usually limited to large academic centers).

Anecdotally I know of ENT people working in US (large cancer center) without US board certification, on an institution sponsored visa (not sure what type). I am not sure if board certification affects billing for these people or not.  

So overall getting medical license in US is easy, but board certification varies by specialty. For example small rural places in US desperate for doctors will accept someone without FM boards (eg. a resident with 1-2 years experience in IM/FM, etc). Again their employment model is very different, so I guess that could open certain doors and close other doors.

 

Yea, there are specific immigration exceptions for MDs made for rural need in the US but those communities seem rough to work in based on my understanding.

[shikimate]

1 hour ago, blah1234 said:

Yea, there are specific immigration exceptions for MDs made for rural need in the US but those communities seem rough to work in based on my understanding.

Yeah might wanna include a bullet proof vest and armormax windows as a sign on bonus. 

[jnuts]

On 2/24/2021 at 11:11 AM, shikimate said:

Yeah might wanna include a bullet proof vest and armormax windows as a sign on bonus. 

I think it's more that the hospitals aren't profitable (high ratio of medicare to commercial payors) so the contracts are really shitty. 

[Edict]

On 2/4/2021 at 1:23 AM, Jack Marcos said:

Not sure if you know the answer to this, but you seem to have pretty good insight. So I’ll ask anyways lol
1) do you know how US residencies view Canadian medical students? What would be the most important things to focus on to get into a US residency? is it really possible to get US residency coming from Canada?
 

2) I know some recent Canadian neurosurgeons who moved to the US but like you said they cannot become board certified if they did a Canadian residency, so what are the major limitations without being board certified? Is it harder to do academic or private practice without board certification.

2) The answer to your question is that you don't need board certification to practice in the US. You do need to have your FRCSC aka your Royal College certification however.

[Edict]

It really is a combination of factors, but one of the biggest issues is that being a staff cardiac/neuro surgeon is very challenging and likely more challenging than people think. It is almost impossible with current selection criteria to predict who will be a successful cardiac/neuro surgeon from medical school. The selection process for medical school focuses of good academics and social skills which are important in a physician, but only part of what is looked at for surgery. We rarely look at technical skills, leadership, high stress/teamwork in the residency application process, but these are often more important to train a successful surgeon.

We do train more residents in cardiac/neuro and a number of other surgical specialties than we need and part of the reason is call (more so in some than others) but another reason is they want to be able to weed out those not suited. I like to say entering a surgical residency is just the first step, it is an opportunity to try and become a surgeon, not a golden ticket. Unfortunately, surgical reimbursement has declined relative to other specialties in recent years while the work life balance has remained the same (hours have dropped slightly but length of training is longer) and the risk/reward ratio simply is not optimal anymore and it truly is hard to recommend to anyone without an undying passion or love for the field.

[1D7]

Not directly related to your post OP but a well known LHSC (Western University) cardiac surgeon recently left his post for an American job. As far as I know there is no reciprocity between the Canadian and American boards in his specialty. https://lfpress.com/news/local-news/top-heart-surgeon-quits-claims-cardiac-care-not-priority-at-lhsc

So yeah finding a job abroad happens, though in his case I'm sure his decades of excellence and publications helped substantially.

Something else to consider here is that even when you reach your goal of becoming an attending surgeon with a job, there's no guarantee you'll be happy. Hospital funding runs very tight and multiple provincial governments have been outright hostile to physicians in recent years.

[jnuts]

On 3/12/2021 at 11:28 PM, Edict said:

It really is a combination of factors, but one of the biggest issues is that being a staff cardiac/neuro surgeon is very challenging and likely more challenging than people think. It is almost impossible with current selection criteria to predict who will be a successful cardiac/neuro surgeon from medical school. The selection process for medical school focuses of good academics and social skills which are important in a physician, but only part of what is looked at for surgery. We rarely look at technical skills, leadership, high stress/teamwork in the residency application process, but these are often more important to train a successful surgeon.

We do train more residents in cardiac/neuro and a number of other surgical specialties than we need and part of the reason is call (more so in some than others) but another reason is they want to be able to weed out those not suited. I like to say entering a surgical residency is just the first step, it is an opportunity to try and become a surgeon, not a golden ticket. Unfortunately, surgical reimbursement has declined relative to other specialties in recent years while the work life balance has remained the same (hours have dropped slightly but length of training is longer) and the risk/reward ratio simply is not optimal anymore and it truly is hard to recommend to anyone without an undying passion or love for the field.

Sure....

Other notable positive factors in recent neuro staff selection criteria: 

Did you marry your program director?

Did you support a certain faculty member in a recent academic coup? 

Have you shamelessly publication jumped?

I really wish the post above were true, but I think the truth is a LOT messier. 

[jnuts]

On 3/13/2021 at 10:27 AM, 1D7 said:

Not directly related to your post OP but a well known LHSC (Western University) cardiac surgeon recently left his post for an American job. As far as I know there is no reciprocity between the Canadian and American boards in his specialty. https://lfpress.com/news/local-news/top-heart-surgeon-quits-claims-cardiac-care-not-priority-at-lhsc

So yeah finding a job abroad happens, though in his case I'm sure his decades of excellence and publications helped substantially.

Something else to consider here is that even when you reach your goal of becoming an attending surgeon with a job, there's no guarantee you'll be happy. Hospital funding runs very tight and multiple provincial governments have been outright hostile to physicians in recent years.

I can clarify here.  American board certification is not required to work in the US in general.  If you pass all the Steps (or in some States they'll take the LMCE) you can get a licence to practice medicine.  

There are definitely work arounds that allow you to work with just the RC.  

The barrier to practicing without American board certification is at the hospital and local predominant insurance provider level.  By-laws can be changed and insurance companies can be reasoned with if the employer wants to put the effort in.  They are much more likely to do that for an established practitioner they really want than a new grad. 

Having or not having American board certification has no effect on visa requirements, you're still in the IMG bag there unless you have other status in the US.

Bottom-line is that if you can get American certification, get it done to increase your job options.  If not, there are sometimes options but expect those options to be more limited.

[zoxy]

On 3/13/2021 at 10:27 AM, 1D7 said:

Not directly related to your post OP but a well known LHSC (Western University) cardiac surgeon recently left his post for an American job. As far as I know there is no reciprocity between the Canadian and American boards in his specialty. https://lfpress.com/news/local-news/top-heart-surgeon-quits-claims-cardiac-care-not-priority-at-lhsc

So yeah finding a job abroad happens, though in his case I'm sure his decades of excellence and publications helped substantially.

Something else to consider here is that even when you reach your goal of becoming an attending surgeon with a job, there's no guarantee you'll be happy. Hospital funding runs very tight and multiple provincial governments have been outright hostile to physicians in recent years.

Wanted to add that the surgeon who left was one of the last cardiac surgeons in Canada to do a full GenSx residency before an additional three year cardiac residency. He's eligible for the American Board of Surgery. Although I'd wager being a leader in minimally invasive cardiac surgery was more important. There are other Canadian trained cardiac surgeons without American boards at UCSD, Mt. Sinai in Manhattan, UPenn,  Vanderbilt, University of Kansas, The Brigham, and Cleveland University Hospitals off the top of my head. I know another two who are back in Canada but had jobs at Northwestern and Baylor before coming back, so it seems like for CVsx big American hospitals do employ surgeons with Canadian boards.

As for NSx, I know four off the top of my head that are in the US.  Three that did a pediatric NSx fellowship and another that did a spine fellowship. The spine surgeon is in a small Upper Midwest town but he's probably better compensated than any NSx in Canada.

[zoxy]

On 2/23/2021 at 9:30 PM, jnuts said:

Seems a little egotistical on the Canadian side.  The decision is ultimately up to the American Boards to allow or not allow Canadian applicants. The Americans set and revise their criteria for acceptable training all the time without consulting Canadians.  If anything, I think the restrictions are a protectionist pressure from the American side to prevent possible flooding of their market (if they think about Canadians at all).

There's other evidence of this in the NAFTA agreement (or whatever it's called now).  Most Canadian professionals, including lawyers, nurses, and RTs can just show up at the boarder with a job offer and get a TN visa on the spot. There's a specific carve out that prevents Canadian medical doctors from accessing TNs so they have to get the far more restricted and onerous H1bs or J1s. Thank the AMA for that one. 

The more interesting question is why do any of the American Boards allow Canadians to sit their exams? 

https://travel.state.gov/content/travel/en/us-visas/employment/visas-canadian-mexican-nafta-professional-workers.html

I know this is late but are you sure it was the AMA and not the Canadian government's fault that Canadian doctors can't get TN visas? NAFTA negotiation in the early 90's coincided with the Bob Rae government in Ontario and federal austerity that resulted in the reduction of transfer payments.The 90's were the peak of the physician brain drain from Canada. I read in a study that in 1996 for example, there was a net loss of 513 physicians to the US, which equalled 30 percent of the annual output from Canadian medical schools at the time.

The brain drain was biggest for Neurosurgery as Canadian residents who started their training before 1998 were board eligible in the US, and neurosurgeons in the US are the highest earners by far. Previously, while Ontario trained 6 neurosurgeons a year, only 1 or 2 would end up practising in Ontario and there was an acute shortage in neurosurgeons as recently as 2005. So it made a lot of sense for the Royal College and the government to make it harder for Canadian surgeons to leave. Of course, they made it much harder for neurosurgeons to leave without reducing the number of training spots, and that's how we ended up in the situation where there are no jobs and it's getting worse every year.

Anecdotally, I read about a neurosurgeon who started his Canadian residency in 1999 right after the end of reciprocity, then went to Yale to finish his residency and be board eligible in the US.

IMO, the Americans are actually far more accepting of Canadian trainees than the Royal College is of American trainees. Even specialties that are a year shorter in Canada like FM, Plastics, and Gastroenterology are board certifiable in the US. Many states also accept the LMCC. I don't think the AMA are particularity concerned with Canadian doctors taking their jobs. They're far more worried about mid levels and Medicare for All abolishing private insurance and the ensuing government monopsony. Plus, physician training in the US has held steady since the late 90's and will not be able to cope with the population increase. In the US, residency spots are funded by medicare and haven't increased since the 90's, while the population has increased by 50 million and gotten older.

[jnuts]

On 4/4/2021 at 8:00 PM, zoxy said:

I know this is late but are you sure it was the AMA and not the Canadian government's fault that Canadian doctors can't get TN visas? NAFTA negotiation in the early 90's coincided with the Bob Rae government in Ontario and federal austerity that resulted in the reduction of transfer payments.The 90's were the peak of the physician brain drain from Canada. I read in a study that in 1996 for example, there was a net loss of 513 physicians to the US, which equalled 30 percent of the annual output from Canadian medical schools at the time.

The brain drain was biggest for Neurosurgery as Canadian residents who started their training before 1998 were board eligible in the US, and neurosurgeons in the US are the highest earners by far. Previously, while Ontario trained 6 neurosurgeons a year, only 1 or 2 would end up practising in Ontario and there was an acute shortage in neurosurgeons as recently as 2005. So it made a lot of sense for the Royal College and the government to make it harder for Canadian surgeons to leave. Of course, they made it much harder for neurosurgeons to leave without reducing the number of training spots, and that's how we ended up in the situation where there are no jobs and it's getting worse every year.

Anecdotally, I read about a neurosurgeon who started his Canadian residency in 1999 right after the end of reciprocity, then went to Yale to finish his residency and be board eligible in the US.

IMO, the Americans are actually far more accepting of Canadian trainees than the Royal College is of American trainees. Even specialties that are a year shorter in Canada like FM, Plastics, and Gastroenterology are board certifiable in the US. Many states also accept the LMCC. I don't think the AMA are particularity concerned with Canadian doctors taking their jobs. They're far more worried about mid levels and Medicare for All abolishing private insurance and the ensuing government monopsony. Plus, physician training in the US has held steady since the late 90's and will not be able to cope with the population increase. In the US, residency spots are funded by medicare and haven't increased since the 90's, while the population has increased by 50 million and gotten older.

Not bad arguments.  Possibly Canada contributed by not advocating for TN rights for physicians when the carve out was created. But at the end of the day it's a US immigration policy that was pushed by the AMA.  

I don't really accept the position that because the US physician population is worried about mid-levels they can't also be worried about also competing with FMGs. (Incidentally, surgeons aren't generally affected by advancing mid-level providers) 

Lastly, individual physicians don't determine national policy, but they form aggregate advocacy groups to lobby for their interests.  Supply gaps relative to demand favour physicians.

It's also a trend that the US is becoming less accessible to Canadians due to increasing barriers on the US side.

IMO, the US in general doesn't directly care about Canadian physician migration (it's peanuts in the larger picture).  They do care about the perceived encroachment of FMGs in general.  However, physician advocacy groups and certification bodies controlled by physicians have a vested interest in keeping the labour supply scarce.  The State has some interest in increasing the supply (though conflicted when it comes to training resources) but is generally vulnerable to the outsized advocacy of special interests -- in this case physicians groups.  In this case, that has lead to increasingly isolationist policies over time. 

[zoxy]

9 hours ago, jnuts said:

Not bad arguments.  Possibly Canada contributed by not advocating for TN rights for physicians when the carve out was created. But at the end of the day it's a US immigration policy that was pushed by the AMA.  

I don't really accept the position that because the US physician population is worried about mid-levels they can't also be worried about also competing with FMGs. (Incidentally, surgeons aren't generally affected by advancing mid-level providers) 

Lastly, individual physicians don't determine national policy, but they form aggregate advocacy groups to lobby for their interests.  Supply gaps relative to demand favour physicians.

It's also a trend that the US is becoming less accessible to Canadians due to increasing barriers on the US side.

IMO, the US in general doesn't directly care about Canadian physician migration (it's peanuts in the larger picture).  They do care about the perceived encroachment of FMGs in general.  However, physician advocacy groups and certification bodies controlled by physicians have a vested interest in keeping the labour supply scarce.  The State has some interest in increasing the supply (though conflicted when it comes to training resources) but is generally vulnerable to the outsized advocacy of special interests -- in this case physicians groups.  In this case, that has lead to increasingly isolationist policies over time. 

Can you talk about what those increasing barriers are?

I know NSx and CVSx lost board certification, but pretty much all other Canadian specialties are board certifiable. I think that since the vast majority of American hospitals are non-profits, they're not subject to the H1B cap. And as long as a Canadian physician has the USMLEs and can find a hospital that wants to employ them, the rest shouldn't be too difficult.  I think if you somehow get a greencard (EB-1, EB-2,marriage), you wouldn't even need the USMLEs as many states accept the LMCC in lieu of the USMLEs.

[jnuts]

On 4/6/2021 at 11:35 AM, zoxy said:

Can you talk about what those increasing barriers are?

I know NSx and CVSx lost board certification, but pretty much all other Canadian specialties are board certifiable. I think that since the vast majority of American hospitals are non-profits, they're not subject to the H1B cap. And as long as a Canadian physician has the USMLEs and can find a hospital that wants to employ them, the rest shouldn't be too difficult.  I think if you somehow get a greencard (EB-1, EB-2,marriage), you wouldn't even need the USMLEs as many states accept the LMCC in lieu of the USMLEs.

I think I've beaten this to death in other posts, but briefly, the US isn't like Canada.  Just getting a licence is easy.  The barriers are getting malpractice insurance, getting the diverse private insurers to accept you as a provider, and getting privileges at a (or more commonly multiple) hospitals.  It is a huge mistake to not complete the USMLEs if you'd like to work in the US. One or more of those entities will want to see them.

For more information on how FMGs are treated in the US, check out studentdoctor.com.  

My lived experience as a surgeon who's relocated is that Canadians aren't treated any better and have very limited advantages over the general pool of IMGs. Opportunities for FMG surgeons in the US have not improved in the last decade.  H1b visas are very difficult to obtain and compromises are usually made to get one. 

[Jack Marcos]

Updated questions: I was wondering if you know of many neurosurgeons Canadian trained that went to the US recently? I know it’s not possible to become board eligible anymore.

1) I have heard it’s possible but most stories are from neurosurgeons deep into their career with many academic accolades to their name, is it possible to train in Canada and then do a fellowship or two + PhD and go straight to the US upon graduation?

2) is it only possible to do academic neurosurgery coming from Canada in the states or is it possible to do hospital based/private practice down the road as well?

[Edict]

1 hour ago, Jack Marcos said:

Updated questions: I was wondering if you know of many neurosurgeons Canadian trained that went to the US recently? I know it’s not possible to become board eligible anymore.

1) I have heard it’s possible but most stories are from neurosurgeons deep into their career with many academic accolades to their name, is it possible to train in Canada and then do a fellowship or two + PhD and go straight to the US upon graduation?

2) is it only possible to do academic neurosurgery coming from Canada in the states or is it possible to do hospital based/private practice down the road as well?

1) It is possible and there are people who don't even have a PhD, in the US they care more about fellowship and clinical abilities, networking is important so some US experience is helpful

2) Definitely possible to do both 

https://surgery.utoronto.ca/division-neurosurgery-alumni-where-are-they-now

[Jack Marcos]

28 minutes ago, Edict said:

1) It is possible and there are people who don't even have a PhD, in the US they care more about fellowship and clinical abilities, networking is important so some US experience is helpful

2) Definitely possible to do both 

https://surgery.utoronto.ca/division-neurosurgery-alumni-where-are-they-now

 

 

awesome to hear! 
do you have any examples of recent Canadian residents working in private practice? I didn’t know it was possible since it’s so hard to get a VISA.

 

thanks

[Edict]

I know of some but my advice is you look through online profiles. Its not hard to get a visa as long as you write your USMLEs. I think there is truth that in the US without a network you are by definition at a disadvantage, but if you are well trained and establish yourself there is no reason they won't try to take you.