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When do med students in Canada write STEP 1 if pursuing a match in the US?

Can you apply to both residencies? I remember reading that the timeliness are a bit different which may mean if you match in the US you're removed from CaRMS.

Do the same things make one competitive in both countries?

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 Traditionally the US has heavily valued both Step1 and to a lesser extent Step 2CK i.e. standardized test scores; Canada has been much more about letters, electives, research, ECs - more subjective.. (although these matter in very competitive specialties in the US too)

Few CMGs have tried matching into the US recently.  Partly, this is because the time needed to ace Step 1 detracts from other activities needed to stay competitive in Canada  as US med schools teach to Step 1 to varying degrees while Canadian schools don't.

Now that Step 1 is going P/F it may allow CMGs better opportunities to cross apply.  Step 1 should be written ideally just after all pre-clinical activities (e.g. end of 2nd year in 4 year school).  It seems that Step 2 CK may replace Step 1.   Although it's a much better test, closer to clinical and the LMCC1, just like any standardized test it takes some preparation to do really well.

I think everything is hypothetical given the COVID situation, but US elective(s) would probably help match to the US, but may come at the opportunity cost of a Canadian ones.  Cross-applying does risk spreading oneself thin.  

Most of the time the Canadian match happens before the US match - this has allowed Canadian USMGs to apply to some choice/desired programs in Canada and "back up" in the US.  At the moment, with COVID, the US match is finishing well-before any Canadian match.

 But, one must declare participation in both matches, and if one matches in Canada first then one is withdrawn from the US match and vice-versa.  

There are a lot more programs in the US of varying quality - matching to CaRMS is by far the path of least resistance for most CMGs.  

Many programs tend to be competitive in both countries - there are some notable exceptions like Ortho in Canada vs US and Peds in the US vs Canada.  But, generally, applying to the US won't be put you at an advantage given the extra-overhead/work and the need for visa, etc..  

I can see applying to the US as a strategy for unmatched CMGs in competitive specialties as acing Step 2 CK and having previously passed Step 1 may allow them to be competitive to lesser-known US programs while re-applying to CaRMS.  But, otherwise, unless one really wishes to do residency in the US for other reasons, the extra-time/effort may detract from normal med student activities.  

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In the US, Step scores and research are more important than in Canada and electives are relatively less important.

Generally the SF Match runs before CaRMS which runs before the NRMP match. If you applied and matched through any of these, you'd automatically be withdrawn from other matching services. SF match only does Ophtho, other specialties are run by the NRMP in the US. Of course currently CaRMS runs later due to COVID.

So that means that if you were to match to your last ranked program in Canada, FM in Nunavut, you'd automatically be withdrawn from the NRMP, even if you were first on Barrow's Neurosurgery rank list. If you wanted to guarantee matching to the US, you'd have to risk skipping out on CARMS. Ophtho is the exception because the SF match runs before NRMP and you'd get taken out of CaRMS if you matched there.

Additionaly, electives, which are called away rotations in the US, are not required  for many non-competitive specialties but are crucial for competitive ones. If you want Neurosurgery, Ortho, ENT,Urology, Plastics then you will need them in the US as well. If you want IM, GenSx, FM, then you don't need them. Additionally, away rotations are usually four weeks in length in the US. If you do four weeks down there, then you'd only have 4 weeks in your desired specialty in Canada with the stupid AFMC 8 week cap on electives in a particular specialty. The AFMC cap specifically says that people applying to the US for residency are also subject to it.

Furthermore, even if you match down there, you can't get an H1B since you won't be eligible for Step3, and you won't be eligible for OPT status that international graduates use as a bridge between their F1 student visa and the H1B that they get after taking Step3 during their PGY1 year. You'll be forced to get the dreaded J1 with its two year return to Canada requirement after finishing residency.

As you can see, matching to the US is not easy and it's continuously getting harder. I would only recommend spending time and effort on it if you're interested in one of three specialties. NSx, Ophtho, and Derm are maybe the only specialties where I'd put effort into matching to the US. Of course, some people on this forum will say even that shouldn't be attempted and any additional time should be spent making your application stronger for CaRMS but I disagree for those three. Otherwise, since most other specialties in Canada aren't particularity competitive and you'll be board eligible in the US if you do residency here, staying here is the best choice. 

Ophtho becuase it's less competetive down there and since the SF match runs before CaRMS, you won't have to risk skipping CaRMS to go unmatched in the US. Derm isn't too risky as you'd apply to Canada for Derm(and only Derm, no backups), then apply to the US for Derm and your backup speclaities of IM or FM which are extremely noncompetitive down there and you'd be guaranteed to match into the backups. NSx because the job market in Canada is horrendous and is one of two Canadian specialties that is not board eligible down there. Especially consider it for NSx. For example, there's an RCPSC certified NSx surgeon who's doing another NSx residency down in the US after finishing one in Ontario and also doing a year of fellowship in Canada. Clearly, it would have served him best if he'd started down there to begin with.  Of course there are also Canadian grads who do end up getting jobs in Canada after the requisite PhD and fellowships.

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4 hours ago, zoxy said:

As you can see, matching to the US is not easy and it's continuously getting harder. I would only recommend spending time and effort on it if you're interested in one of three specialties. NSx, Ophtho, and Derm are maybe the only specialties where I'd put effort into matching to the US. Of course, some people on this forum will say even that shouldn't be attempted and any additional time should be spent making your application stronger for CaRMS but I disagree for those three. Otherwise, since most other specialties in Canada aren't particularity competitive and you'll be board eligible in the US if you do residency here, staying here is the best choice. 

Actually I think if someone really wanted Pediatrics then it would make sense to consider applying to the US.  In Canada, it's almost as competitive as ENT whereas in the US it's essentially non-competitive for US MDs and considered very "IMG friendly".

4 hours ago, zoxy said:

NSx because the job market in Canada is horrendous and is one of two Canadian specialties that is not board eligible down there. Especially consider it for NSx. For example, there's an RCPSC certified NSx surgeon who's doing another NSx residency down in the US after finishing one in Ontario and also doing a year of fellowship in Canada. Clearly, it would have served him best if he'd started down there to begin with.  Of course there are also Canadian grads who do end up getting jobs in Canada after the requisite PhD and fellowships.

NSx in Canada is notorious - I saw a MD/PhD (from U/T), post-fellowship x n years, recently start a FM residency -total waste of their time/effort/sacrifice.  It's such a waste of resources too - it makes no sense to graduate heavily subsidized trainees with zero job prospects.  But, programs aren't accountable to the total cost - they just see the value in having a trainee, regardless of whether the trainee has any real, long-term, career possibilities (bit like many PhD programs in academia).  NSx definitely has much better prospects in the US where it's very competitive - but,  I'm not sure whether doing a single elective would be enough to match there.   However, given the poor prospects in Canada it still might make it worthwhile.

However, for the other two programs (Derm and Ophtho), I can't see that the extra-time needed to write both Step 1 and Step 2 CK would justify the potential gain as opposed to say research or CV "buffing" in Canada.  I think an exception could be during a "year off" (which seems to be increasingly popular) or if unmatched - otherwise spending months on Steps, might simply detract from making oneself competitive for CaRMS.   But, with a viable Canadian Derm/Ophtho app and a good Step 2 CK, one could try applying to low tier US programs.  Peds is the only "side door" into derm through a pediatric-derm fellowship.

4 hours ago, zoxy said:

So that means that if you were to match to your last ranked program in Canada, FM in Nunavut, you'd automatically be withdrawn from the NRMP, even if you were first on Barrow's Neurosurgery rank list. If you wanted to guarantee matching to the US, you'd have to risk skipping out on CARMS. Ophtho is the exception because the SF match runs before NRMP and you'd get taken out of CaRMS if you matched there.

Nice point regarding SF match.  To be fair, if one were on the verge of Barrow (with excellent Step), then I think it's unlikely one would apply to Nunavut (unless one had a desire to do remote medicine), as there would be many more possibilities in the US.  

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29 minutes ago, indefatigable said:

However, for the other two programs (Derm and Ophtho), I can't see that the extra-time needed to write both Step 1 and Step 2 CK would justify the potential gain as opposed to say research or CV "buffing" in Canada

I'm considering the US to increase chances for cardiac surgery or maybe general. Do you have any insight on those specialties in this context?

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35 minutes ago, indefatigable said:

Pediatrics then it would make sense to consider applying to the US.  In Canada, it's almost

I try my best to forget kids exist. Guess I succeeded. Peds is very uncompetitive in the US. Something like 40 percent of kids are on Medicaid in some states and metro ares and Medicaid will pay much less than what Medicare pays, let alone private insurance. Most peds-specialties and sub-specialties make much less than their adult equivalent in the US. I don't know how it is in Canada but I'd guess it's not as extreme.

 

35 minutes ago, indefatigable said:

NSx in Canada is notorious - I saw a MD/PhD (from U/T)

I saw a CVSx surgeon in exactly the same situation.

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13 minutes ago, AB27 said:

I'm considering the US to increase chances for cardiac surgery or maybe general. Do you have any insight on those specialties in this context?

Just do GenSx in Canada and then a 2-3 year ACGME CT fellowship down there. That path would only be a year or two longer than an I6 with the added benefit of dual board certification. As for matching to an I6 out of med school, you'll 100 percent need US electives for matching there. I6 thoracic is very competitive. GenSx would be a much easier match and wouldn't require electives.

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44 minutes ago, CaRMS2021 said:

Which is the other? Family Medicine since its 2 not 3 years? 

Fam is eligible with certain conditions. Other one is cardiac surgery. Not a coincidence that NSx and CVSx have the worst job market of all surgical specialties. Also why OP wants to go the US since they like CVSx. Wonder if OP will stay interested when they realize that CVSx does the same four procedures over and over again.

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55 minutes ago, indefatigable said:

Actually I think if someone really wanted Pediatrics then it would make sense to consider applying to the US.  In Canada, it's almost as competitive as ENT whereas in the US it's essentially non-competitive for US MDs and considered very "IMG friendly".

 

24 minutes ago, zoxy said:

I try my best to forget kids exist. Guess I succeeded. Peds is very uncompetitive in the US. Something like 40 percent of kids are on Medicaid in some states and metro ares and Medicaid will pay much less than what Medicare pays, let alone private insurance. Most peds-specialties and sub-specialties make much less than their adult equivalent in the US. I don't know how it is in Canada but I'd guess it's not as extreme.

The practice of pediatrics in the US and pediatrics in Canada are quite different. US pediatrics residency is 3 years and extremely primary-care focused. US general pediatricians in general are considered primary-care doctors and most children see a pediatrician for routine visits and immunizations etc, instead of a family doctor like they would in Canada. Outside of saturated markets in Canada, outpatient pediatricians are generally consultant specialists who get referrals from primary care for complex patients and non-routine issues. Based on this doing a fellowship after the 3 years is very common in the US, and now there's an official 2 year "hospital pediatrics" fellowship, which is now being seen more and more as a requirement for inpatient jobs, whereas in Canada the training is 4 years and outside of tertiary care centres, a general pediatrician can do inpatient pediatrics out of residency.

It is also true that the majority of pediatric subspecialities make the same or less than general pediatricians in the US, based on their billing systems. That's not the case in Canada as far as I know, although pediatric subspecialists make less than their adult subspecialist colleagues, in general.

So should a Canadian MD apply to peds in the US? With the US match being first I can't recommend it. With Step 1 being pass/fail it's going to be a few cycles before people figure out what American PDs are looking for in Canadian applicants and if step 2 takes over I don't know when the best time to write it would be, because the somewhat equivalent LMCC1 is written after the match, too late. The other hurdle is the 3 year length means that you would need a fellowship or a chief year to get the required 4 years to be certified in Canada. Although I do know of one person who finished US residency and then was accepted to a Canadian pediatrics residency for a 4th year, which simplifies things.

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1 hour ago, zoxy said:

Wonder if OP will stay interested when they realize that CVSx does the same four procedures over and over again.

Lol I'm very open to changing my mind when shadowing is allowed again. I mostly was leaning to gen surg + thoracic fellowship but I also really like learning about heart anatomy and physiology. The job market definitely scares me, 4 procedures is not a deal breaker- probably an issue in a lot of specialties.

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22 hours ago, AB27 said:

And this would allow a person to practice as a CT or general surgeon in either country?

Three year one definitely would and the two year one would require another year of super-fellowship to qualify for Royal College Boards. It used to be the de facto and de jure path before the 90's anyway. Look at pathway 2 in Royal College the document I linked.

One of the surgeons at Sunnybrook and the head of congenital CVSx at UBC did two year ACGME fellowships in the US. Also the former head of CVSx surgery at Western who decamped to the US last year did a full GenSx residency before three years of CVSx in Canada. Also another surgeon at UCalgary I think who did this more recently, in the 2000s I think.

Another way would be to do a 5 year vascular surgery residency in Canada followed by a 2-3 year ACGME fellowship in the US. Not sure if that would qualify for Canadian training but it would certainly qualify for US boards.

You could also do your 6 years of Cardiac training in Canada and then do an ACGME fellowship in the US. This would make you board eligible for cardiac surgery in the US but you wouldn't be board eligible for GenSurg the US or Canada. Would also take a year longer than doing GenSurg followed by an ACGME fellowship. But I'd imagine your skills would be really good at this point. Maybe you could use the US training to do more complex stuff.

Don't think you should be concerned about the ability to come back to Canada. When they don't even offer people with PhDs, fellowship, and residency all at the same institution a position, you certainly won't get one if you do your Cardiac training in the US. If you want to stay in Canada, do your training in Canada. It's unlikely to me that they'd skip a Canadian trained applicant to give a newly trained US candidate a job.  

If I were in your shoes I'd stay in Canada for Cardiac residency but if it seemed like the prospects of getting a job were slim, I'd do a two year fellowship in the US to get board certification. You probably wouldn't even need that anyway. I know of more than ten Canadian trained CVSx who don't have American boards but are practising down there. They're all at academic institutions though.  

 

22 hours ago, AB27 said:

Lol I'm very open to changing my mind when shadowing is allowed again. I mostly was leaning to gen surg + thoracic fellowship but I also really like learning about heart anatomy and physiology. The job market definitely scares me, 4 procedures is not a deal breaker- probably an issue in a lot of specialties.

As in General Thoracic(US or Canada) or Cardio-Thoracic(US) fellowship?

 

Links:

https://www.royalcollege.ca/rcsite/documents/ibd/cardiac_surgery_str_e

https://www.abts.org/ABTS/CertificationWebPages/Pathways to Certification.aspx

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2 hours ago, bearded frog said:

So should a Canadian MD apply to peds in the US? With the US match being first I can't recommend it. With Step 1 being pass/fail it's going to be a few cycles before people figure out what American PDs are looking for in Canadian applicants and if step 2 takes over I don't know when the best time to write it would be, because the somewhat equivalent LMCC1 is written after the match, too late. The other hurdle is the 3 year length means that you would need a fellowship or a chief year to get the required 4 years to be certified in Canada. Although I do know of one person who finished US residency and then was accepted to a Canadian pediatrics residency for a 4th year, which simplifies things.

Typically the Canadian match occurs first - COVID has disrupted normal timing.  This has previously allowed USMGs to apply to CaRMS and back-up with NRMP.  So a Peds gunner could try doing the same if things went back to normal.  If not, then I agree there would be less utility except in unmatched situation.

The Steps would remain a hurdle, but many IMGs and some CMGs write the LMCC1 before their fourth year.  In theory, with a bit of work Step 2 could be squeezed in at the same time.  

The difference in Peds practice/training between the two countries are similar to the ones in IM.  Just like IM, an extra-year of residency would be needed, but apparently many US-trained internists are able to make it back to Canada.

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13 minutes ago, zoxy said:

As in General Thoracic(US or Canada) or Cardio-Thoracic(US) fellowship?

 

General thoracic in Canada. Its just the idea of going through so much debt and training to do Cardiac surgery then not being employable is absolutely terrifying. At the same time I don't want to regret not going for something I'm interested in. 

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Just now, AB27 said:

General thoracic

GOAT specialty. If you want to be miserable like the Cardiac surgeons, you can be just as miserable with Thoracic. Just do ECMO and Lung Transplant and you can be as sad as anyone. But if you don't do those things you can have a great lifestyle with General Thoracic.

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20 hours ago, indefatigable said:

Typically the Canadian match occurs first - COVID has disrupted normal timing.  This has previously allowed USMGs to apply to CaRMS and back-up with NRMP.  So a Peds gunner could try doing the same if things went back to normal.  If not, then I agree there would be less utility except in unmatched situation.

The Steps would remain a hurdle, but many IMGs and some CMGs write the LMCC1 before their fourth year.  In theory, with a bit of work Step 2 could be squeezed in at the same time.  

The difference in Peds practice/training between the two countries are similar to the ones in IM.  Just like IM, an extra-year of residency would be needed, but apparently many US-trained internists are able to make it back to Canada.

I am aware of the current reversal with covid, which is why I specified that I cannot recommend it at all with the US currently being first, although if it goes back to being second it is an option. However I question if spending the time to study to pass step 1 and get a compeditive step 2 score, and in theory doing an American elective or two? to build a somewhat compeditive US application would be worth the sacrifice in elective time/sanity time potentially taking away from the primary circadian application.

I agree that if you do start a US peds residency that you can make it back to Canada without too many hurdles, as I said there are multiple options to get the required time in, however it's an added complication.

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29 minutes ago, bearded frog said:

However I question if spending the time to study to pass step 1 and get a compeditive step 2 score, and in theory doing an American elective or two?

Electives are not necessary at all for pediatrics. Maybe for med-peds but not for regular pediatrics. Only 60 percent of pediatric spots are filled by US MDs. While that's higher than FM and IM, it's still pretty low compared to other specialties. You don't need a great Step scores either. In 2020 the mean Step1 score for matched applicants was 228 and Step2 score was 245. For context a 230 Step1 is 43rd percentile and a 245 Step2 is 46th percentile for US MDs and CMGs. And that's mean as well so half of applicants did worse(assuming a normal distribution where mean=median). You definitely don't need good scores to be competitive. Unmatched applicants had Step1 of 215 and Step 2 of 232 for comparison. That's 19th percentile for Step1 and 25th percentile for Step2.

Unrelated but I wonder how the Royal College would treat med-peds for licensing.

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17 hours ago, CaRMS2021 said:

Anyone care to weigh in why Peds is so competitive in Canada? What am I missing here?

It's not why is Peds so competetive in Canada but why is peds so uncompetitive in the US.

As @bearded frog explained above, the practice of pediatrics is very different in Canada vs the US. In most of Canada, especially in some provinces like BC, pediatricians are fully fledged specialists that accept referrals from primary care physicians to provide specialized care. In the US, most pediatricians without specialty training function as primary care physicians. Sort of like an FM that only sees kids. Accordingly the US needs to train more pediatricians per capita to provide this sort of care than Canada does.

For example there were 104 pediatrics spots in all of Canada for CaRMS 2021. In the US however, there were 2864 Peds spots and 390 med-peds spots for the 2020 match. While the US has approximately 9 times Canada's population, they have 30 times the number of pediatrics spots. Simple supply and demand explains why it's so competitive in Canada with such a reduced supply.

Another issue that I outlined above is the sort of insurance that kids in the US have. In the US people have three main kinds of insurance: Private, Medicare(65+), Medicaid(Poor people's insurance). As a rule of thumb, private insurance pays 40-90 percent more than Medicare, while Medicaid pays 30 percent less than Medicare . As I mentioned above, in some states and metro areas 40-50 percent of kids are on Medicaid (technically called CHIP). As a whole, children's medicaid(CHIP) covers 37 million kids. So if you're a pediatrician, close to half of your patients will be paying much lower fees than if you saw old people(Medicare) or working age adults(private insurance). So a pediatrician in the US will on average earn less than a regular a primacy care FM physician who sees adults, due to a greater proportion of patients having low paying insurance.

The same pattern isn't limited to general pediatrics but holds true in almost every pediatric sub-specialty. For example, Peds-Ortho earns less than General-Ortho,  Peds-Nephro earns less than adult Nephro, Peds-Cards earns half of adult Cardiology, and Peds-NSx makes less than adult NSx.

Since kids and poor young people who are the type to have kids on Medicaid don't vote, there is no political pressure on politicians to increase healthcare spending for kids in the US.

In conclusion, the US trains a lot of pediatricians and then underpays them relative to even FM by barely funding Medicaid. That's why it's not competitive. Not even the warm and fuzzies can overcome low pay for most folks.

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10 hours ago, zoxy said:

It's not why is Peds so competetive in Canada but why is peds so uncompetitive in the US.

As @bearded frog explained above, the practice of pediatrics is very different in Canada vs the US. In most of Canada, especially in some provinces like BC, pediatricians are fully fledged specialists that accept referrals from primary care physicians to provide specialized care. In the US, most pediatricians without specialty training function as primary care physicians. Sort of like an FM that only sees kids. Accordingly the US needs to train more pediatricians per capita to provide this sort of care than Canada does.

For example there were 104 pediatrics spots in all of Canada for CaRMS 2021. In the US however, there were 2864 Peds spots and 390 med-peds spots for the 2020 match. While the US has approximately 9 times Canada's population, they have 30 times the number of pediatrics spots.

Another issue that I outlined above is the sort of insurance that kids in the US have. In the US people have three main kinds of insurance: Private, Medicare(65+), Medicaid(Poor people's insurance). As a rule of thumb, private insurance pays 40-90 percent more than Medicare, while Medicaid pays 30 percent less than Medicare . As I mentioned above, in some states and metro areas 40-50 percent of kids are on Medicaid (technically called CHIP). As a whole, children's medicaid(CHIP) covers 37 million kids. So if you're a pediatrician, close to half of your patients will be paying much lower fees than if you saw old people(Medicare) or working age adults(private insurance). So a pediatrician in the US will on average earn less than a regular a primacy care FM physician who sees adults, due to a greater proportion of patients having low paying insurance.

The same pattern isn't limited to general pediatrics but holds true in almost every sub specialty. For example, Peds-Ortho earns less than General-Ortho,  Peds-Nephro earns less than Adult-Nephro, and Peds-NSx makes less than adult NSx.

Since kids and poor young people who are the type to have kids on Medicaid don't vote, there is no political pressure on politicians to increase healthcare spending for kids in the US.

In conclusion, the US trains a lot of pediatricians and then underpays them relative to even FM by barely funding Medicaid. That's why it's not competitive. Not even the warm and fuzzies can overcome low pay for most folks.

Since the care of children is provided by specialists instead of GPs, do children in America receive a higher standard of care? Or is it equivalent (I believe both FM and Peds are 3 years down there?)

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24 minutes ago, CaRMS2021 said:

Since the care of children is provided by specialists instead of GPs, do children in America receive a higher standard of care? Or is it equivalent (I believe both FM and Peds are 3 years down there?)

Highly doubt it but that would be an interesting study to do :D they're both equivalent to primary care docs and not as extensively trained as internists or pediatricians here. If anything, the poor funding structure and pay disparity might even affect care negatively.

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Supply and demand is the main reason front and centre, there are simply few peds spots in Canada compared to the US.

But yes there is a pattern of practice difference too, but it is not fair to equate that as being "less qualified" - those that go on to do sub-specialty in the US are not suddenly incompetent in comparison. 

As for Canadian patterns of practice - yes, many peds are "specialists" in that they accept and take referrals from FM docs on an outpatient basis. Often though, FM will just punt off slightly more complex kids to peds, because they know peds will actually get paid for the 30-45 mins it takes to manage the kid and arrange follow up, not because its suddenly complex work. I know multiple pediatrics providers who also do routine immunizations etc for their patients, because they wanted a primary care longitudinal aspect of care to their clinic too - simply just keep getting their actual family doctor to re-refer to keep seeing them.  Arguably even general outpatient peds who take referrals will often deal with basic bread and butter management, that i'm sure the US based peds just manage on a regular basis too...except our system pays them better than the US and Canadian FM because they get to bill a consult fee for the first visit (and often q6-12months when their FM doc "re-refers" them), for loads of basic presentations  that they are referred either because FM has tried to deal with it without much luck(because its clearly something that isn't an easy fix, but also not life threatening at all, and simply anxious parents0, and wants to pass off to a "higher authority" for patient reference (and usually, you will get a letter back saying "yes FM doc I agree with your assessment and plan, keep doing what you're doing. I can follow up with them too".  Not to mention all the basic peds issues that get seen in emerg and "since this patient doesn't have a FM doc, lets just refer them for out patient peds follow up so someone can lay eyes on them on this likely benign rash/insert other basic FM issue".

It's a great system here for pediatrics is the summary, for often not very medically difficult work in an outpatient setting  - but dealing with anxious parents and ADHD/?autism/?learning disorder/?failure to thrive/ functional abdominal pain vs ?ibs patients all day long can be emotionally draining.  That's also why they get paid the big consultation fees.

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39 minutes ago, DrOtter said:

Highly doubt it but that would be an interesting study to do :D they're both equivalent to primary care docs and not as extensively trained as internists or pediatricians here. If anything, the poor funding structure and pay disparity might even affect care negatively.

I think there is a misconception that pediatrics is suddenly inferior in the US based on 3 years alone, depending on the setting you're working in. In Canada, not all 5 year peds work in hospital, and many do mostly outpatient management. Most of the pediatricians i work with will be the first to say you do not need 5 year of residency to do outpatient pediatrics if that is your goal. At a certain point, you've gotten enough out of residency, that you can continue to do your CME learning and refining skills while in practice.  Of course if you are working mostly inpatient, then yes 5 years >3 years.  Many in the US will do fellowships as well, and lets not forget the basic part that US residencies objectively work residents at least slightly harder than Canadian residencies. Non-surgical specialties in Canada, do a good job usually of respecting work hour limits and protected academic time etc, not always, but on average. 

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21 hours ago, zoxy said:

Electives are not necessary at all for pediatrics. Maybe for med-peds but not for regular pediatrics. Only 60 percent of pediatric spots are filled by US MDs. While that's higher than FM and IM, it's still pretty low compared to other specialties. You don't need a great Step scores either. In 2020 the mean Step1 score for matched applicants was 228 and Step2 score was 245. For context a 230 Step1 is 43rd percentile and a 245 Step2 is 46th percentile for US MDs and CMGs. And that's mean as well so half of applicants did worse(assuming a normal distribution where mean=median). You definitely don't need good scores to be competitive. Unmatched applicants had Step1 of 215 and Step 2 of 232 for comparison. That's 19th percentile for Step1 and 25th percentile for Step2.

I do not disagree that US peds is relatively less compeditive from a stats perspective, as you point out, but I figured US schools would want to see you do an elective or two in the states to demonstrate actual interest in doing residency in the US (just as you hear with anecdotes about people who only do electives in Ontario getting met with skepticism when they apply across the country).

11 hours ago, zoxy said:

It's not why is Peds so competetive in Canada but why is peds so uncompetitive in the US.

Agree with your post here. Although it starts to get into a further discussion about how FM is different in the US and Canada. In the US you can just call up the local ENT and get an appointment without having to be referred, so US primary care plays somewhat of a different role in general. I'd be interested to know if US FM de-emphasizes routine peds stuff as pediatricians are seen as primary care for children.

1 hour ago, CaRMS2021 said:

Since the care of children is provided by specialists instead of GPs, do children in America receive a higher standard of care? Or is it equivalent (I believe both FM and Peds are 3 years down there?)

Depends on the definition of "specialist" but Canadian FM does the same things that US peds does, and I don't know if the training difference for bread and butter well-child stuff would be significant a few years into practice when it becomes routine. Certainly Canadian FM is trained in primary pediatric care and expected to be familiar with it to pass their exams. Family doctors' actual comfort with some pediatric stuff obviously varies so some may be quicker to refer to peds than others.

33 minutes ago, JohnGrisham said:

But yes there is a pattern of practice difference too, but it is not fair to equate that as being "less qualified" - those that go on to do sub-specialty in the US are not suddenly incompetent in comparison.

Agree. And without looking up the actual data I assume a larger proportion of US peds residents go on to fellowship (In Canada it's anecdotally 50%), especially now that hosptial pediatrics is a thing in the US.

35 minutes ago, JohnGrisham said:

As for Canadian patterns of practice - yes, many peds are "specialists" in that they accept and take referrals from FM docs on an outpatient basis. Often though, FM will just punt off slightly more complex kids to peds, because they know peds will actually get paid for the 30-45 mins it takes to manage the kid and arrange follow up, not because its suddenly complex work. I know multiple pediatrics providers who also do routine immunizations etc for their patients, because they wanted a primary care longitudinal aspect of care to their clinic too - simply just keep getting their actual family doctor to re-refer to keep seeing them.  Arguably even general outpatient peds who take referrals will often deal with basic bread and butter management, that i'm sure the US based peds just manage on a regular basis too...except our system pays them better than the US and Canadian FM because they get to bill a consult fee for the first visit (and often q6-12months when their FM doc "re-refers" them), for loads of basic presentations  that they are referred either because FM has tried to deal with it without much luck(because its clearly something that isn't an easy fix, but also not life threatening at all, and simply anxious parents0, and wants to pass off to a "higher authority" for patient reference (and usually, you will get a letter back saying "yes FM doc I agree with your assessment and plan, keep doing what you're doing. I can follow up with them too".  Not to mention all the basic peds issues that get seen in emerg and "since this patient doesn't have a FM doc, lets just refer them for out patient peds follow up so someone can lay eyes on them on this likely benign rash/insert other basic FM issue".

It's a great system here for pediatrics is the summary, for often not very medically difficult work in an outpatient setting  - but dealing with anxious parents and ADHD/?autism/?learning disorder/?failure to thrive/ functional abdominal pain vs ?ibs patients all day long can be emotionally draining.  That's also why they get paid the big consultation fees.

This is highly variable by location and provider. I've worked in outpatient peds clinics across the country and, as you say, some pediatricians do more primary care stuff by their own choice, or their local area is saturated (ie Mississauga) and they do primary care to maintain their patient volume. Elsewhere, pediatricians have 6m wait lists and turn down referrals for routine things. The follow-up from emerg thing is probably location specific too, because at my local centre emerg says to follow up with their FD and only refers to peds for the more complex stuff (because they know their not gonna get seen within the next few weeks anyway). Even when I discharge someone from hospital, we ask them to follow up with their FD unless it's a complex case or multiple issues etc. This will obviously vary by ER/hospital policy.

I agree that the Canadian system of consultant pediatrics vs US primary care is a better system. We do 4+ years of specialist training that is increasingly in demand. Also as I alluded to above I also think Canada's system of the FD as the medical home with continuity throughout the lifespan with referral for secondary care is superior to the US system (with the caveat that there needs to be enough FDs available to see patients... another conversation entirely). However, I disagree with assertion that outpatient consultant pediatrics is not medically difficult work. We really don't see the easy stuff, even when we see a constipation it's usually refractory having failed initial treatment or a complex social situation, which are not easy fixes, because every FD can prescribe PEG 3350. But the majority of patients that I've seen at least have been medically complex, or the FTT/chronic abdo pain NYD/chronic headache NYD/behaviour/social complications. And "big consultation fees" is a misnomer, when you need to spend >1 hour seeing a patient to address complex medical/social issues, and you bill less for the consult than the ENT next door who sees a patient in 10 minutes. ;)

48 minutes ago, JohnGrisham said:

I think there is a misconception that pediatrics is suddenly inferior in the US based on 3 years alone, depending on the setting you're working in. In Canada, not all 5 year peds work in hospital, and many do mostly outpatient management. Most of the pediatricians i work with will be the first to say you do not need 5 year of residency to do outpatient pediatrics if that is your goal. At a certain point, you've gotten enough out of residency, that you can continue to do your CME learning and refining skills while in practice.  Of course if you are working mostly inpatient, then yes 5 years >3 years.  Many in the US will do fellowships as well, and lets not forget the basic part that US residencies objectively work residents at least slightly harder than Canadian residencies. Non-surgical specialties in Canada, do a good job usually of respecting work hour limits and protected academic time etc, not always, but on average. 

Just to clarify this, peds residency in Canada is 4 years for general peds, however you can start fellowship after either 3 or 4 years of residency (so 5 or 6 years total for most fellowships). Although this will change in the future so that you need to finish all 4 years before fellowship. Also you are very correct in that US residency is much harder on residents. The vast majority of residents don't have a union/PARO equivalent etc. so they generally get paid less and do much more call. We talked to US peds residents at the AAP conference and they basically had one weekend off a month, which is brutal. Does this give them a better education? Debatable ha.

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