Help Me Decide (USMD vs. Potential Canada MD)

[LongAgoPlacebo]

Hi all,

After an expensive cycle of applying broadly to both Canada and the US, I'm very privileged to have three USMD acceptances (Stony Brook, Wayne State, New York Medical College). I'm also on the waitlist at some other USMD schools, in particular SKMC at Thomas Jefferson, University of Maryland, and George Washington. On the Canadian side, I am waiting post-II for a MUN OOP decision some time in May and a decision from University of Montreal at the end of this month.

My goal is to eventually practice in Canada in the specialty of my choice. I don't mind doing residency in the US if it helps me enter that specialty. I've read https://forums.premed101.com/topic/104759-georgetown-usmd-vs-ubc/ and they cover some interesting points, but I thought to ask here for more specific advice about my situation. Yes, I know that the usual comment is to go to medical school in the country you want to practice in...but there's a complication.

Right now, I'm interested in ophthalmology and anesthesia. Since interests may change in the next four years, I generally want to keep options as open as possible. I know ophtho is currently in the top 3 most competitive specialties in Canada, while it drops to more of a top 10 most competitive in the US. Gas, on the other hand, is mildly competitive in both countries. Since the US supply of positions is literally 10-20x larger than Canada's (despite only having 7-8x as many MD medical students, goes to 9-10x counting MD + DO), Canadian students sometimes (often?) apply there to boost their chances of matching (see more below).

In Canada, it seems applicant competitiveness is mostly a function of clinical performance to get great letter of recs + good research productivity in the field of interest, i.e. grades don't matter. Historically, US applicant competitiveness involved the same in addition to strong USMLE Step 1 performance and to a lesser degree pre-clinical grades. Step 1 will be pass/fail starting next year, so the jury's out on how that will affect things. Some people argue it will make applying almost the same as in Canada, while most think school reputation/prestige will matter more and USMLE Step 2 will end up being the replacement for the 'need' of a numerical score to screen applicants.

USMDs are generally more open about sharing where their graduating students match, so I was able to peruse the match lists of the above mentioned schools. Out of my current acceptances, Stony Brook has the best outlook for both ophtho and gas, and matches very decently in NE USA (which keeps me close to family/friends in Canada). Considering the schools who waitlisted me, the only one clearly better is SKMC at Jefferson, who has an ophtho program ranking top 3 in the US. I have decent odds of getting off the waitlist at SKMC, and it would be great to have research/mentor connections to a strong home program.

I know relatively little about the Canadian side. I heard school reputation is not a big deal in Canada, i.e. any med school prepares you well and it's on you as the student to get your application competitive enough for your specialty choice. I'm also aware something like a third of Canada's ophtho spots are at Quebec's three French schools, which locks out any applicant who doesn't know French. My French is fine, but I presume going to University of Montreal would still give me an upper hand there. In contrast, MUN does not have an ophtho program, so I miss out on home program advantage.

Outside of COVID, the Canadian CaRMS match day usually occurs something like two weeks before the US NRMP match day. Considering that the first successful match to take place is binding and cancels any subsequent match, the general advice is to apply to Canada for your most competitive specialty and use the US as backup for the same. This enables you to avoid dual applying in Canada to an undesired backup specialty, while boosting odds of matching at your most desired specialty. However, the US ophthalmology match in particular happens two months before CaRMS (for some reason). Since ophtho reverses the advice pattern but gas does not, it makes it very unclear how I would rank programs in the US or in Canada to maximize odds of matching. Another variable is if I'm a USMG or CMG applicant due to potential 'home country' advantage. More precisely, applying as a Canadian USMG to a US residency is better than as a CMG, and conversely applying as a CMG to a Canadian residency is better than as a Canadian USMG. The benefit for the latter case apparently is not as significant, since school reputation is not really a factor in Canada. 

In any case, my question is this: suppose I want to apply ophtho in four years, I want to maximize my odds of getting in to later practice in Canada, and my application is similarly competitive in both countries, do I stand a better chance going to USMD or Canada MD? In either situation, I will surely apply to programs in both countries; maybe highly ranked ophtho programs in US and broadly to Canadian ophtho/gas programs considering the timeline and competitiveness.

Yes, USMD is 5x more expensive in comparison, but I worry more about matching to my desired specialty in four years. I assume that coming back to practice in Canada after spending residency/fellowship in the US is relatively straightforward: pass the MCC and Royal College exams and then find a job. Please correct me if I'm naive and the Canadian market for US-trained ophthalmologists is actually awful. (As an aside for gas, the whole CRNA independent practice legal battle in the US seems to make anesthesia residency in the US quite undesirable, never mind practicing there as an attending.) 

Also if anyone has some inside scoop about any of the schools I mentioned (Canadian or US), I'd really appreciate hearing your perspective! I am obviously overly optimistic about gaining a Canadian acceptance and having this problem, but it might also spark some good debate useful to others.

Thanks a lot and sorry for the wall of text!

 

[shikimate]

I just have 1 question: are you a citizen or green card holder of the USA? 

Ophtho is still very competitive in USA, so I am curious if J1 visa sponsorship would become an issue at all? I do remotely know someone who did undergrad in Canada, went to USMD, matched to ophtho in USA, and now practices in USA, but I cannot vouch their citizenship status.

[indefatigable]

Ophtho in Quebec can be sometimes not that competitive despite the very high renumeration.  Getting admitted to Montreal would probably be your best chance, as it would give you obvious inroads (i.e. contacts and research opportunities), and would save you (and/or your family) a small fortune.

Wherever you end up, you should try to "cherry-pick" a Montreal ophtho elective which could give you better openings in QC (i.e. you don't have to all of medicine in French for ophtho).      

The visa-issue could also be non-negligible - a non-US citizen will be less favoured for residency than American citizens.  Passing US Boards is also generally much easier than passing the Royal College, not to mention the lack of networking compared to a local graduate when looking for a job.  

[zoxy]

11 hours ago, shikimate said:

I just have 1 question: are you a citizen or green card holder of the USA? 

Ophtho is still very competitive in USA, so I am curious if J1 visa sponsorship would become an issue at all? I do remotely know someone who did undergrad in Canada, went to USMD, matched to ophtho in USA, and now practices in USA, but I cannot vouch their citizenship status.

If you're a foreign graduate from a US program you initially go on OPT status and your residency program then gets you an H1B after you pass Step3. Because this process is not that time sensitive and you can spend considerable time on OPT status, the programs don't have to pay extra for premium processing, considerably reducing the cost of sponsoring an H1B for the program. This OPT option is only available to those who graduate from the US and can go on OPT status.

[zoxy]

18 hours ago, LongAgoPlacebo said:

In any case, my question is this: suppose I want to apply ophtho in four years, I want to maximize my odds of getting in to later practice in Canada, and my application is similarly competitive in both countries, do I stand a better chance going to USMD or Canada MD? In either situation, I will surely apply to programs in both countries; maybe highly ranked ophtho programs in US and broadly to Canadian ophtho/gas programs considering the timeline and competitiveness.

Yes, USMD is 5x more expensive in comparison, but I worry more about matching to my desired specialty in four years. I assume that coming back to practice in Canada after spending residency/fellowship in the US is relatively straightforward: pass the MCC and Royal College exams and then find a job. Please correct me if I'm naive and the Canadian market for US-trained ophthalmologists is actually awful. (As an aside for gas, the whole CRNA independent practice legal battle in the US seems to make anesthesia residency in the US quite undesirable, never mind practicing there as an attending.) 

Also if anyone has some inside scoop about any of the schools I mentioned (Canadian or US), I'd really appreciate hearing your perspective! I am obviously overly optimistic about gaining a Canadian acceptance and having this problem, but it might also spark some good debate useful to others.

Thanks a lot and sorry for the wall of text!

 

To answer your question, unless you go to a Top20 school in the US, going to a Canadian school will generally be the best option if you want to match back in Canada. A US school of course will be better for matching to the US.

However, one of the places you highlighted, Jefferson Medical College, has one of if not the best ophthalmology program in the US. The Wills Eye Hospital is the oldest ophthalmology hospital in the US and was established in 1832 to give you some context about it's prestige and calibre. Jefferson should give you the best chance of doing research and getting letters for matching Ophto. Anaesthesia isn't a tough match for US MDs. If you want it and don't have red flags, you'll get it. Ophto while more difficult than anaesthesia, is a much easier match in the US than in Canada. After all you only have a 1 in 2 chance of matching to Ophto in Canada.

If you do get into both MUN and Montreal, Montreal would be hands down the one to choose. MUN doesn't have an Ophto residency while Montreal has 5 spots. Home school advantage and ease of doing research favors Montreal. Go to MUN if you like icebergs, darkness, and three meters of snow during the winter.

Another issue that I don't think you stated is that the length of training for those two specialties in the US is 4 years while in Canada it's 5 years. If you do your residency there, it will be a challenge to get the royal college to deem your residency equivalent and to practice in Canada as a specialist. I think you'd need to do an extra year of residency in Canada for royal college certification but don't know how easy getting that extra year would be.

Is practising in the US not an option for you? It would make the decision so much easier if you're hellbent on doing Ophtho and the cost of a US MD is not an issue.

[bearded frog]

8 hours ago, LongAgoPlacebo said:

I'm very privileged to have three USMD acceptances (Stony Brook, Wayne State, New York Medical College). I'm also on the waitlist at some other USMD schools, in particular SKMC at Thomas Jefferson, University of Maryland, and George Washington. On the Canadian side, I am waiting post-II for a MUN OOP decision some time in May and a decision from University of Montreal at the end of this month.

Here's the important part of your post. If you don't get in to Canada, then matriculate in the states, there should be absolutely no question about this, DO NOT give up your USMD acceptances hoping to apply again. Most US schools will screen applicants with previous acceptances and you'll be shutting a lot of doors. And, as you say, the US is a viable route. Now if you get into Canada, usually the advice is that for most people who plan to work in Canada, there is little benefit to USMD over Canadian without US citizenship/green card. It's usually more expensive, and you have to go through the STEP system etc, deal with visas, harder to network/do electives in Canada, etc. You are correct that optho is extremely compeditive on both sides of the border. For sheer numbers the US is better, but you are at a disadvantage for US residency needing a visa. I do not know how much of a disadvantage, and if it cancels out the numbers advantage. In any case even if you gun optho there is a realistic chance that you'll unfortunately not match (or decide to pursue a different specialty), in which case I cannot see an advantage going USMD.

Realistically, most Canadian MDs do not apply to the US match unless they are dual citizens as you're at a disadvantage for STEPs (doing it on your own time and USMD teaches to the exam unlike Canadian MD) and at a disadvantage needing a visa, although you are a tier above IMG.

Personally, take the USMD and run if you don't get a Canadian acceptance, and go down the path you describe conflict free. If you get in to either MUN or UdeM stay in Canada, and I personally would even if I was do or die optho. You're correct that you will be somewhat better off for optho having the french programs open to you, and going to MUN doesn't close the door to this, not having a home program is a disadvantage but someone at MUN has ranked optho first for the last 3 years of the match (although carms doesn't say if they were successful or not) so clearly there is some infrastructure. And unless you're gunning plastics or derm really no other advantage to USMD. If you get into both UdeM and MUN then I would go UdeM for the reasons you specified.

[LongAgoPlacebo]

7 hours ago, shikimate said:

I just have 1 question: are you a citizen or green card holder of the USA? 

Ophtho is still very competitive in USA, so I am curious if J1 visa sponsorship would become an issue at all? I do remotely know someone who did undergrad in Canada, went to USMD, matched to ophtho in USA, and now practices in USA, but I cannot vouch their citizenship status.

Ah, I should have mentioned explicitly that I'm just a Canadian citizen. No PR or citizen status in the US. I think in general the J1 visa is available at nearly all academic hospitals (which are my preferred programs at this time) since ECFMG handles the sponsorship paperwork. Nonetheless, an American USMG would certainly be preferred to a Canadian USMG, all else being equal. Like bearded frog said, it's unclear when all's said and done if the benefit of more program spots in the US is outweighed by the stigma against Canadian USMGs needing a visa when applying (even if Canadian > general IMG).

For the more premium H1B visa (which avoids the 2 year home country requirement after training completion), I hear it's pretty rare to get it straight out of F-1 student visa. This is due to the sponsoring hospital technically having to bear the expensive application cost (~10k?). But then again, I also hear some sketchier programs will let (force?) the applicant pay for their own H1B visa application fees. Overall, the consensus is H1B isn't something to count on.

 

6 hours ago, zoxy said:

If you're a foreign graduate from a US program you initially go on OPT status and your residency program then gets you an H1B after you pass Step3. Because this process is not that time sensitive and you can spend considerable time on OPT status, the programs don't have to pay extra for premium processing considerably reducing the cost of sponsoring an H1B. This OPT option is only available to those who graduate from the US and can go on OPT status.

Thanks for the info! I didn't know about OPT status being a potential gateway to H1B. Do you know if this is widespread or only a perk at a minority of programs? I presume even then obtaining the H1B is not guaranteed due to the lottery process. So it seems the two options from USMD -> US residency is (1) train under J1 visa and return home at the end of training or (2) get agreement with program that they will sponsor H1B visa, go on OPT status for up to 12 months, then pray to receive an H1B visa in the interim to continue training from month 12 onward? Since I actually want to return to Canada after training, it would seem (1) is fine and is the most straightforward route, or am I wrong?

 

12 hours ago, indefatigable said:

Ophtho in Quebec can be sometimes not that competitive despite the very high renumeration.  Getting admitted to Montreal would probably be your best chance, as it would give you obvious inroads (i.e. contacts and research opportunities), and would save you (and/or your family) a small fortune.

Wherever you end up, you should try to "cherry-pick" a Montreal ophtho elective which could give you better openings in QC (i.e. you don't have to all of medicine in French for ophtho).      

The visa-issue could also be non-negligible - a non-US citizen will be less favoured for residency than American citizens.  Passing US Boards is also generally much easier than passing the Royal College, not to mention the lack of networking compared to a local graduate when looking for a job.  

Thanks for the insight! Yes, I agree an elective ophtho rotation in Quebec would be necessary regardless of where I end up.

[LongAgoPlacebo]

10 hours ago, zoxy said:

To answer your question, unless you go to a Top20 school in the US, going to a Canadian school will generally be the best option if you want to match back in Canada. A US school of course will be better for matching to the US.

However, one of the places you highlighted, Jefferson Medical College, has one of if not the best ophthalmology program in the US. The Wills Eye Hospital is the oldest ophthalmology hospital in the US and was established in 1832 to give you some context about it's prestige and calibre. Jefferson should give you the best chance of doing research and getting letters for matching Ophto. Anaesthesia isn't a tough match for US MDs. If you want it and don't have red flags, you'll get it. Ophto while more difficult than anaesthesia, is a much easier match in the US than in Canada. After all you only have a 1 in 2 chance of matching to Ophto in Canada.

If you do get into both MUN and Montreal, Montreal would be hands down the one to choose. MUN doesn't have an Ophto residency while Montreal has 5 spots. Home school advantage and ease of doing research favors Montreal. Go to MUN if you like icebergs, darkness, and three meters of snow during the winter.

Another issue that I don't think you stated is that the length of training for those two specialties in the US is 4 years while in Canada it's 5 years. If you do your residency there, it will be a challenge to get the royal college to deem your residency equivalent and to practice in Canada as a specialist. I think you'd need to do an extra year of residency in Canada for royal college certification but don't know how easy getting that extra year would be.

Is practising in the US not an option for you? It would make the decision so much easier if you're hellbent on doing Ophtho and the cost of a US MD is not an issue.

Yes, Jefferson is looking pretty nice from the ophtho perspective and is currently my top choice out of all the USMDs that still have me in the running. They have a great general reputation as well, so if my interests change I'll be well-supported there too.

I chuckled at the MUN description, though I suspect you're exaggerating at least a bit. I'm no stranger to lots of snow, and I'd be pretty happy to spend four years of med school close to nature. I also don't think the amount of daylight is significantly different from other Canadian cities. Regardless, I agree with you that UdeM is better from the ophtho viewpoint. One complication I didn't mention: UdeM's program will likely be 5 years for me because my undergrad major does not qualify me to skip their pre-med year, whereas MUN's is 4 years in all cases. Is UdeM still the clear winner over MUN now?

Financially it makes sense to pick MUN due to the presumed one year of attending salary difference down the road. But maybe the extra year at UdeM can be spent solidifying mentor/research connections and being productive, and therefore building a more competitive application? What if I don't match to ophtho straight from MUN and need to take a 5th year doing research and reapplying (seems to be a rising trend in Canada for competitive specialties)? It all comes out in the wash then.

For the duration of training difference, my understanding is that US-trained residents in a specialty with a shorter duration than the Canadian counterpart usually take a fellowship year in the US to make up the lacking year. The alternative you mentioned of getting that extra year in Canada could also work, maybe as some type of Canadian fellow working under attending supervision. I don't know how competitive ophtho fellowships are in the US or in Canada. Thanks for pointing out this issue, though!

Unfortunately, I want to practice in Canada for several reasons. I really like the philosophy of our healthcare system much better, the rarity of litigation against medical professionals, and all of my family/friends are in Canada. My SO and I would prefer to raise a family in Canada as well. Lastly and perhaps the most moot point, I have little interest in becoming a US PR or citizen (a soft requirement of practicing in the US), and then also dealing with worldwide taxation issues if ever I leave and become a nonresident.

[zoxy]

2 hours ago, LongAgoPlacebo said:

Ah, I should have mentioned explicitly that I'm just a Canadian citizen. No PR or citizen status in the US. I think in general the J1 visa is available at nearly all academic hospitals (which are my preferred programs at this time) since ECFMG handles the sponsorship paperwork. Nonetheless, an American USMG would certainly be preferred to a Canadian USMG, all else being equal. Like bearded frog said, it's unclear when all's said and done if the benefit of more program spots in the US is outweighed by the stigma against Canadian USMGs needing a visa when applying (even if Canadian > general IMG).

For the more premium H1B visa (which avoids the 2 year home country requirement after training completion), I hear it's pretty rare to get it straight out of F-1 student visa. This is due to the sponsoring hospital technically having to bear the expensive application cost (~10k?). But then again, I also hear some sketchier programs will let (force?) the applicant pay for their own H1B visa application fees. Overall, the consensus is H1B isn't something to count on.

 

Thanks for the info! I didn't know about OPT status being a potential gateway to H1B. Do you know if this is widespread or only a perk at a minority of programs? I presume even then obtaining the H1B is not guaranteed due to the lottery process. So it seems the two options from USMD -> US residency is (1) train under J1 visa and return home at the end of training or (2) get agreement with program that they will sponsor H1B visa, go on OPT status for up to 12 months, then pray to receive an H1B visa in the interim to continue training from month 12 onward? Since I actually want to return to Canada after training, it would seem (1) is fine and is the most straightforward route, or am I wrong?

 

You actually can't get an H1B straight after an F1. You need all three USMLE's for an H1B and you can't take Step3 until after graduation. An H1B right after medical school is impossible. You must go on an OPT if you don't want to take a gap year between finishing medical school and starting residency. I know it sounds absolutely insane but most US immigration laws are idiotic anyway.

And that's where the temporary OPT status comes in. You can be on OPT status for a total of 36 months so you could actually finish IM or FM on it and never have to deal with a J1 or H1B. Of course that won't work for Ophtho and Anesthesiology and you'll need an H1B for those two. 

As for a J1, it's definitely the easiest for you and the program and has very little cost for both of you but it condemns you to coming back to Canada after finishing you residency. There are escape routes like an O1 visa or a rural waiver but they're difficult to get or not worth it. An H1B provides max flexibility.

As for the ease of getting a residency with OPT and then an H1B, even programs who only accept J1s explicitly make exceptions for non Americans who have US MDs. Mayo and Stanford are examples of two of those programs off the top of my head. I personally know two people on H1Bs in the US after a US MD but that's a sample size of 2 and not exactly trustworthy. I would recommend contacting some of the Canadian students at Wayne State and Stony Brook since those two traditionally have many Canadian students who would be in your exact position. They would know much better than this forum which is extremely US phobic.

I think I need to clarify the bit about premium processing a bit more. For most IMG applicants since the start of residency in late June or early July is very close to match day, it doesn't leave enough time for the programs to get the resident a regular H1B. They must pay for express processing and lawyers to make sure the residents have their visas by the start date. Since you will have OPT status that is not available for IMGs, they can do regular processing that takes eight months or so after you take your Step3 which would make it cheaper for your program.

 

[LongAgoPlacebo]

10 hours ago, bearded frog said:

Here's the important part of your post. If you don't get in to Canada, then matriculate in the states, there should be absolutely no question about this, DO NOT give up your USMD acceptances hoping to apply again. Most US schools will screen applicants with previous acceptances and you'll be shutting a lot of doors. And, as you say, the US is a viable route. Now if you get into Canada, usually the advice is that for most people who plan to work in Canada, there is little benefit to USMD over Canadian without US citizenship/green card. It's usually more expensive, and you have to go through the STEP system etc, deal with visas, harder to network/do electives in Canada, etc. You are correct that optho is extremely compeditive on both sides of the border. For sheer numbers the US is better, but you are at a disadvantage for US residency needing a visa. I do not know how much of a disadvantage, and if it cancels out the numbers advantage. In any case even if you gun optho there is a realistic chance that you'll unfortunately not match (or decide to pursue a different specialty), in which case I cannot see an advantage going USMD.

Realistically, most Canadian MDs do not apply to the US match unless they are dual citizens as you're at a disadvantage for STEPs (doing it on your own time and USMD teaches to the exam unlike Canadian MD) and at a disadvantage needing a visa, although you are a tier above IMG.

Personally, take the USMD and run if you don't get a Canadian acceptance, and go down the path you describe conflict free. If you get in to either MUN or UdeM stay in Canada, and I personally would even if I was do or die optho. You're correct that you will be somewhat better off for optho having the french programs open to you, and going to MUN doesn't close the door to this, not having a home program is a disadvantage but someone at MUN has ranked optho first for the last 3 years of the match (although carms doesn't say if they were successful or not) so clearly there is some infrastructure. And unless you're gunning plastics or derm really no other advantage to USMD. If you get into both UdeM and MUN then I would go UdeM for the reasons you specified.

Thanks very much for your insight! I referenced parts of your post in my previous replies. I am leaning towards staying in Canada if I get lucky at MUN or UdeM.

What do you think about UdeM versus MUN in the situation where the former is 5 years and the latter is 4 years of med school?

[zoxy]

1 hour ago, LongAgoPlacebo said:

Yes, Jefferson is looking pretty nice from the ophtho perspective and is currently my top choice out of all the USMDs that still have me in the running. They have a great general reputation as well, so if my interests change I'll be well-supported there too.

I chuckled at the MUN description, though I suspect you're exaggerating at least a bit. I'm no stranger to lots of snow, and I'd be pretty happy to spend four years of med school close to nature. I also don't think the amount of daylight is significantly different from other Canadian cities. Regardless, I agree with you that UdeM is better from the ophtho viewpoint. One complication I didn't mention: UdeM's program will likely be 5 years for me because my undergrad major does not qualify me to skip their pre-med year, whereas MUN's is 4 years in all cases. Is UdeM still the clear winner over MUN now?

Financially it makes sense to pick MUN due to the presumed one year of attending salary difference down the road. But maybe the extra year at UdeM can be spent solidifying mentor/research connections and being productive, and therefore building a more competitive application? What if I don't match to ophtho straight from MUN and need to take a 5th year doing research and reapplying (seems to be a rising trend in Canada for competitive specialties)? It all comes out in the wash then.

For the duration of training difference, my understanding is that US-trained residents in a specialty with a shorter duration than the Canadian counterpart usually take a fellowship year in the US to make up the lacking year. The alternative you mentioned of getting that extra year in Canada could also work, maybe as some type of Canadian fellow working under attending supervision. I don't know how competitive ophtho fellowships are in the US or in Canada. Thanks for pointing out this issue, though!

Unfortunately, I want to practice in Canada for several reasons. I really like the philosophy of our healthcare system much better, the rarity of litigation against medical professionals, and all of my family/friends are in Canada. My SO and I would prefer to raise a family in Canada as well. Lastly and perhaps the most moot point, I have little interest in becoming a US PR or citizen (a soft requirement of practicing in the US), and then also dealing with worldwide taxation issues if ever I leave and become a nonresident.

I wouldn't worry about the one year's salary difference from a financial standpoint, life is long and the marginal utility of money rapidly diminishes. Besides, 5 years in Montreal isn't too bad.  I'd still pick UdeM over MUN since the extra year at UdeM would let you gun harder for Ophtho. I was obviously joking about MUN as I've never been there myself. I just know they get icebergs close to St.John's and they get a lot of snow. It's actually further south than Vancouver so more daylight during the winter. It could very well be a great school in a great city for all I know. They just don't have 5 Ophtho spots like UdeM though.

But I feel like you'd have the best chance at matching Ophtho in the US, especially if you get into Jefferson. And I would caution against assuming the Royal College would make it easy to come back if you do residency in the US+fellowship. They get a perverse form of pleasure from making people jump through hoops to practice. I would make sure to check this with people who've been in similar positions or the Royal College itself before deciding. I anecdotally know of a graduate from a 4 year ACGME accredited EM programs at an Ivy League school finding it impossible to come back to Canada. This is despite their training being longer than the 3 years of FM+EM that is common in Canada.

And I would also caution against knocking the US before living there. I had similar beliefs to yours before living there myself. The view of the US that most Canadians have is heavily influenced by extremely biased Canadian journalism. According to the Canadian media, every American has a BMI of 53, is getting shot on a daily basis, is uninsured, has never travelled outside their state, and has been medically bankrupt three times. The reality is rather different.

Additionally, you can also always give up your green card and not be subject to the global taxation issue.

 

[bearded frog]

18 minutes ago, LongAgoPlacebo said:

Thanks very much for your insight! I referenced parts of your post in my previous replies. I am leaning towards staying in Canada if I get lucky at MUN or UdeM.

What do you think about UdeM versus MUN in the situation where the former is 5 years and the latter is 4 years of med school?

In the grand scheme of things one year doesn't make a big difference if it gets you towards your career. I think for family or IM or something than that's a reasonable concern, however with your stated goal of optho I think an extra year gives you an extra year to do research, collaborate etc, and worth the trade off for having a local program and easy networking for all the french optho spots. I still think UdeM takes it.

7 minutes ago, zoxy said:

And I would also caution against knocking the US before living there. I had similar beliefs to yours before living there myself. The view of the US that most Canadians have is heavily influenced by extremely biased Canadian journalism. According to the Canadian media, every American has a BMI of 53, is getting shot on a daily basis, is uninsured, has never travelled outside their state, and has been medically bankrupt three times. The reality is rather different.

Apologies to the OP for the following derail: They didn't mention any of those concerns when they specified why Canada. Preferring the Canadian health care system is a very valid argument that I personally agree with. Malpractice costs much more in the US, as they said. The US does have significantly more obesity (38.2% vs 25.8% of men as of 2015) which is potentially related to lack of public/preventative health care. There is obviously more gun violence. And while only ~10% are uninsured, you're sarcastic comment was not far off from the under-insured rate of 43.4% in the US. In any case, there are many reasons why someone would not want to live in the US, especially if you are not a heterosexual white male, if you have been at all paying attention to American politics in the last 5 years.

[zoxy]

31 minutes ago, bearded frog said:

 

Apologies to the OP for the following derail: They didn't mention any of those concerns when they specified why Canada. Preferring the Canadian health care system is a very valid argument that I personally agree with. Malpractice costs much more in the US, as they said. The US does have significantly more obesity (38.2% vs 25.8% of men as of 2015) which is potentially related to lack of public/preventative health care. There is obviously more gun violence. And while only ~10% are uninsured, you're sarcastic comment was not far off from the under-insured rate of 43.4% in the US. In any case, there are many reasons why someone would not want to live in the US, especially if you are not a heterosexual white male, if you have been at all paying attention to American politics in the last 5 years.

I should have probably put an /s after what I said. The US obviously has many problems and I'm not denying them. I just think that everyone should keep an open mind and not be quick to judge other countries before actually living/experiencing them. This holds for any foreign country, including the US. I'm just trying to help OP make an informed and educated decision, not bashing on Canada and saying that there's no reason to practice here.

As for your data, you should look into what constitutes as under insured, since US insurance is so convoluted. I took a class at a US school of public policy on this and that barely scratched the surface. Generally speaking Insurance coverage in the US can be broken down into 4 main categories: Private Insurance, Medicare, ACA/Medicaid, and uninsured. The completely uninsured portion is only 10-11 percent. As for higher malpractice insurance, it is covered by the employer or as a business expense for a private practice. When an American physician reports their earnings, they report it after deducting malpractice insurance.

Anyway, you basically validated my point about Canadians being reflexively anti-American. I'm just saying keep an open mind, not that America is perfect and Canada sucks.

[LongAgoPlacebo]

58 minutes ago, zoxy said:

You actually can't get an H1B straight after an F1. You need all three USMLE's for an H1B and since you can't take Step3 until after graduation. An H1B right after medical school is impossible. You must go on an OPT if you don't want to take a gap year between finishing medical school and starting residency. I know it sounds absolutely insane but most US immigration laws are idiotic anyway.

And that's where the temporary OPT status comes in. You can be on OPT status for a total of 36 months so you could actually finish IM or FM on it and never have to deal with a J1 or H1B. Of course that won't work for Ophtho and Anesthesiology and you'll need an H1B for those two. 

As for a J1, it's definitely the easiest for you and the program and has very little cost for both but it condemns you to coming back to Canada after finishing. There are escape routes like an O1 visa or a rural waiver but not worth it. An H1B provides max flexibility.

As for the ease of getting a residency with OPT and then an H1B, even programs who only accept J1s explicitly make exceptions for non Americans who have US MDs. Mayo and Stanford are examples of two of those programs off the top of my head. I personally know two people on H1Bs in the US after a US MD but that's a sample size of 2 and not exactly trustworthy. I would recommend contacting some of the Canadian students at Wayne State and Stony Brook since those two traditionally have many Canadian students who would be in your exact position. They would know much better than this forum which is extremely US phobic.

I think I need to clarify the bit about premium processing a bit more. For most IMG applicants since the start of residency in late June or early July is very close to match day, it doesn't leave enough time for the programs to get the resident a regular H1B. They must pay for express processing and lawyers to make sure the residents have their visas by the start date. Since you will have OPT status that is not available for IMGs, they can do regular processing that takes eight months or so after you take your Step3 which would make it cheaper for your program.

 

Thanks for the details about the H1B! Makes sense to me now about requiring USMLE Step 3. I just learned about the existence of cap-exempt institutions, so if I'm lucky enough to match at one of those, there is no lottery and an H1B visa is assured after the 12 months on OPT status.

You mentioned OPT status can be maintained for up to 36 months, presumably using the initial 12 months + 24 months of OPT extension. However, it seems medicine is not one of the eligible STEM degree programs for OPT extension (according to https://www.ice.gov/sites/default/files/documents/Document/2016/stem-list.pdf ). So maybe it is necessarily 12 months max of OPT before transition to H1B?

Regardless, the cap-exempt thing makes H1B acquisition easy if I match at such an institution.

51 minutes ago, zoxy said:

I wouldn't worry about the one year's salary difference from a financial standpoint, life is long. Besides, 5 years in Montreal isn't too bad.  I'd still pick UdeM over MUN since the extra year at UdeM would let you gun harder for Ophtho. I was obviously joking about MUN as I've never been there myself. I just know they get icebergs close to St.John's and they get a lot of snow. It's actually further south than Vancouver so more daylight during the winter. It could very well be a great school in a great city for all I know. They just don't have 5 Ophtho spots like UdeM though.

But I feel like you'd have the best chance at matching Ophtho in the US, especially if you get into Jefferson's. And I would caution against assuming the Royal College would make it easy to come back if you do residency in the US+fellowship. They get a perverse form of pleasure from making people jump through hoops to practice. I would make sure to check this with people who've been in similar positions or the Royal College itself before deciding. I anecdotally know of a graduate from a 4 year ACGME accredited EM programs at an Ivy League school finding it impossible to come back to Canada. This is despite their training being longer than the 3 years of FM+EM that is common in Canada.

And I would also caution against knocking the US before living there. I had similar beliefs to yours before living there myself. The view of the US that most Canadians have is heavily influenced by extremely biased Canadian journalism. According to the Canadian media, every American has a BMI of 53, is getting shot on a daily basis, is uninsured, has never travelled outside their state, and has been medically bankrupt three times. The reality is rather different.

Additionally, you can also always give up your green card and not be subject to the global taxation issue.

 

Thanks for this as well!

[zoxy]

On 4/11/2021 at 11:39 PM, LongAgoPlacebo said:

Thanks for the details about the H1B! Makes sense to me now about requiring USMLE Step 3. I just learned about the existence of cap-exempt institutions, so if I'm lucky enough to match at one of those, there is no lottery and an H1B visa is assured after the 12 months on OPT status.

You mentioned OPT status can be maintained for up to 36 months, presumably using the initial 12 months + 24 months of OPT extension. However, it seems medicine is not one of the eligible STEM degree programs for OPT extension (according to https://www.ice.gov/sites/default/files/documents/Document/2016/stem-list.pdf ). So maybe it is necessarily 12 months max of OPT before transition to H1B?

Regardless, the cap-exempt thing makes H1B acquisition easy if I match at such an institution.

Thanks for this as well!

Did not realize that medicine was not a STEM degree! Who would have thought! Guess you're not eligible for the full 36 months then.

I'm not too familiar with the specifics of OPT extensions. It's a piece of policy that is always being tweaked and prodded by each administration. I know that Trump in particular put barriers to OPT extension but I don't know the specifics since it didn't impact me.

And yes, since almost all training programs are non-profits, they're not subject to the H1B cap and you won't go through the lottery. So you'll definitely get an H1B if the program is willing to go through with the hassle and cost of applying for one. It's also what makes moving down to the US for work relatively easy for Canadian healthcare workers. Very few other professions have the luxury of working for non-profits and not being subject to the cap.

Again, check with the Canadians at the Canadian friendly schools to verify everything. They probably know the ins and outs of the system and the difficulty of matching as a Canadian US MD better than me and this forum.

[zoxy]

On 4/11/2021 at 5:03 AM, LongAgoPlacebo said:

 I'm also on the waitlist at some other USMD schools, in particular SKMC at Thomas Jefferson, University of Maryland, and George Washington. On the Canadian side, I am waiting post-II for a MUN OOP decision some time in May and a decision from University of Montreal at the end of this month.

Just realized that one of your options may be GW. Avoid them as their university hospital is owned by a for profit corporation. I think they'd be subject to the cap and lottery for sponsoring an H1B. They've also declined in quality since being bought out by a for profit company. 

I wonder if they're still the default hospital for emergencies at the White House. I think they're only a mile away from there.

[bearded frog]

On 4/11/2021 at 11:22 PM, zoxy said:

As for your data, you should look into what constitutes as under insured, since US insurance is so convoluted.

Oops, I meant to source my data with a link. It's from here https://www.commonwealthfund.org/publications/issue-briefs/2020/aug/looming-crisis-health-coverage-2020-biennial

On 4/11/2021 at 11:22 PM, zoxy said:

Anyway, you basically validated my point about Canadians being reflexively anti-American. I'm just saying keep an open mind, not that America is perfect and Canada sucks.

I'm not reflexively anti-American, I follow both American and Canadian politics quite closely and would say I'm fairly knowledgeable about health care and social issues on both sides of the border. My distaste for America's right-wing politics is quite considered, and pretty much the opposite of reflexive 

[LongAgoPlacebo]

Hey guys,

To provide an update on this topic: I was accepted to UdeM and, after careful consideration of all the factors presented above, the information I was able to glean from public sources, and conversations with some mentors/peers ahead of me, I've decided to go ahead with UdeM! I've withdrawn my USMD acceptances and waitlist positions.

Biggest pros for Canada: Cheap tuition (especially Quebec schools...); close to family/friends; going to school in the country I want to practice in → better Canadian connections for CaRMS (and beyond); get to stay in home country with the health/social/financial/insurance/utility/etc. systems I'm already used to → avoids some not insignificant hassle; similarly, no need to deal with visas.

Biggest cons for Canada: Fewer specialty spots → more fierce competition for top specialties; disadvantage if dual applying to the US NRMP due to lack of US connections (even with elective rotations spent at select US hospitals for this purpose) and having to take USMLE Step 1 + 2 on own time via self-study.

Grey zone for Canada: CaRMS can feel more like a crapshoot than NRMP since students look very similar on the Medical Student Performance Record a.k.a. Dean's Letter. Grades aren't reported in Canada, so the most you get is some narrative summative clinical performance comments for each clerkship. In the US, the Medical Student Performance Evaluation lists preclinical grades if the school isn't P/F for preclinical (some schools still aren't), clinical rotation grades as H/HP/P/F (nearly all schools use this scale), and lastly some narrative overall performance comments at the end. US applicants will also include their USMLE Step 1 score (P/F from 2022 onward) and Step 2 CK score (actually Step 2 CS has been cancelled so just CK is 'Step 2' now). Consequently, getting an interview in Canada depends most on letters of rec > research productivity > ECs in that order I think. There's a rumour some highly competitive Canadian programs have such a hard time differentiating candidates that they request undergrad transcripts as well (I hope it's just to see major and not to assess undergrad GPA competitively...). The interview stage is very significant in Canada to determine rank order, arguably more than in the US where the aforementioned grades and exam scores still hold weight post-interview. So pros of Canada: no need to stress about numerical or tiered grade reporting at any point in the education; cons of Canada: getting strong letters of rec is correlated with excellent clinical performance anyway, your likeability needs to shine in the interview or you risk not being ranked to match. If you're a decently charismatic person with good soft skills, Canada should be fine. If you're socially awkward and historically have relied on strong standardized testing performance to get ahead academically, then you need to work on your soft skills for Canada. 

Biggest pros for UdeM: easier access to residency spots that require fluency in French; probably the best research productivity out of all the French universities; home program in nearly all medical specialties; Montreal is great.

Biggest cons for UdeM: the medical building (Pavillon Roger-Gaudry) is pretty ugly and old on the inside; large class size (>250 at downtown campus) → possibly more competition for opportunities; network hospitals are pretty spread out across Montreal.

Grey zone for UdeM: 5 year program for me due to the required preparatory year → more times for research/connections but also 1 extra year of tuition/rent/life before attending life.

Anyway, this was my thought process. I'll leave this thread unedited for the benefit of others.

If anyone has any questions about applying in the US (2022 cycle opens in a couple weeks) or simultaneously juggling broad applications in both Canada and the US, feel free to PM or continue this thread. I won't promise a reply right away, but certainly within a few days.

[LongAgoPlacebo]

Hi,

As was already discussed elsewhere on this forum, there was a quiet June 2021 media release by the AFMC that Canadian MDs will no longer be accredited by the LCME and likewise USMDs will no longer be accredited by CACMS starting June 30, 2025. I couldn't find the media announcement online anymore so I contacted CACMS for more details because evidently this throws a wrench in the plans of people like me who initially wanted to do USMD and return to Canada for residency. CACMS confirmed the announcement with this:

>>

The accrediting bodies for medical educational programs in the United States and Canada and their sponsors have recently decided that the joint Liaison Committee on Medical Education (LCME) / Committee on Accreditation of Canadian Medical Schools (CACMS) accreditation process for Canadian medical schools put into place eight years ago will conclude in September 2021. At its June 2021 meeting, "the LCME voted that LCME accreditation of Canadian medical schools will cease on June 30, 2025".

<<

They also attached this verbose media announcement:

>>

The accrediting bodies for medical educational programs in the United States and Canada, and their sponsors, are committed to advancing medical education accreditation to meet the future health care needs in each of our countries.  A joint Liaison Committee on Medical Education (LCME)/Committee on Accreditation of Canadian Medical Schools (CACMS) accreditation process for Canadian medical schools which was put into place eight years ago will conclude in September 2021.  

After extensive discussion, the decision was made to implement separate processes going forward in which the CACMS will assume independent accreditation of Canadian medical education programs and the LCME will continue to accredit medical education programs in the United States. The LCME and the CACMS, as well as their American and Canadian sponsors, look forward to continuing a working relationship to share ideas on accreditation innovations and high value solutions while also considering the unique Canadian and United States contexts.

The LCME is sponsored by the Association of American Medical Colleges (AAMC) and the American Medical Association (AMA) and the CACMS is sponsored by the Association of Faculties of Medicine of Canada (AFMC) and the Canadian Medical Association (CMA). The LCME and the CACMS ensure the high quality of medical education programs and have each received full independent recognition from the World Federation on Medical Education as the accreditation bodies for the US and Canada, respectively. In addition, the LCME is fully recognized by and reports to the US Department of Education.

<<

So my understanding is that CMGs will be considered IMG for the NRMP 2026 match and beyond, and likewise Canadian USMGs will be IMG for the CaRMS 2026 match and beyond. This is now a major factor that should strongly sway anyone hesitating between USMD vs Canada MD to choose the latter if they wish to train and arguably even practice in Canada.

Of course not everyone has the luxury of choosing between acceptances, so if Canada remains closed to you after three cycles of trying, trust that USMD is still viable and the next best option. As has been said for years, in general Canada MD > USMD >> US DO >>> Ireland MD ~= Caribbean/Australian/UK MD > other foreign MD. Despite the accreditation change, I think this ranking still holds for securing a residency and becoming a hired attending somewhere in the world.

However specifically for training/practicing in Canada I would change the first > to >>. Note you can still apply to CaRMS as an IMG (Canadian USMG) and this may work out for you if you have program connections, target non-competitive specialties (i.e. mainly FM), and/or know French and apply in Quebec where there is no CMG/IMG distinction (see https://www.carms.ca/match/r-1-main-residency-match/eligibility-criteria/summary-intake-criteria-international-medical-graduates-imgs-province/ ). However there is now more headache because you will have to write the MCCQE1 and NAC/MCCQE2 to show competency, as well as additional specific provincial criteria (assessment of equivalency, ROS).

For CMGs who want to train/practice in the USA, this accreditation change is probably not as harmful as the reverse (Canadian USMGs who want to train/practice in Canada), since the USA is historically known to take in more IMGs due to greater supply of positions per capita. Meanwhile US DO has always been considered IMG for CaRMS so nothing changes here. Other threads on this forum discuss the pros/cons of US DO vs Ireland/Caribbean/Australia/UK IMG for training in the USA vs Canada, so I won't get into it. USMD still comes out ahead for staying in the USA, and probably for a CaRMS application too (cultural connection, easier access to electives = more face time = more chance of interviews).

I am content with my somehow prescient decision to attend a Canadian MD school (and luck in admission), since I currently still envision training/practicing in Canada. All of this to say, I think the analysis has been simplified for choosing between countries. I still disagree with the change and hate the lack of notice/call for comments from stakeholders. I am cynical about the next steps from the CACMS, AFMC, and the CMA that may further restrict, for example, even US-trained Canadians from practicing in Canada. I am worried it is the beginning of another tool to exert control over physician freedom of movement. I am hopeful though that this change is well-intentioned and will lead to improved medical education for both countries.

[bearded frog]

13 hours ago, LongAgoPlacebo said:

words

I agree with all your points. I don't think CMD -> US residency changes much at all since there isn't a separate IMG category. USMD -> CA residency is tougher due to restriction to IMG spots.

I agree that USMD is still the second best option for high chances at a US residency if not successful in CaRMS, which would still be a reasonable path back to practising in Canada, by taking the Canadian boards at the same time as the US one (the caveats of different training time for some specialties apply, of course). I still think that, just as now, not all IMG will be created equal, and the new category of USMD IMG will be a tier above overseas MD IMG.

If anything, the change hurts overseas IMGs more than anything, because it increases the competition for those spots, and how they are, in theory, going up against Harvard/Yale MD applicants, etc.