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I wonder if its real purpose was aimed at incoming IMGs and effectively using CMG fees to subsidize the extremely inefficient cost-structure - this was the essentially the rational behind Step 2 CS.  

IMGs make up a significant proportion of the physician workforce in Canada (25-30%) too, but certification decisions lie completely in the hands of the CFPC and Royal College making the exam extremely costly and redundant.  Maybe it was primarily being used as gatekeeper by some in the CFPC and Royal College.  

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9 minutes ago, indefatigable said:

I wonder if its real purpose was aimed at incoming IMGs and effectively using CMG fees to subsidize the extremely inefficient cost-structure - this was the essentially the rational behind Step 2 CS.  

IMGs make up a significant proportion of the physician workforce in Canada (25-30%) too, but certification decisions lie completely in the hands of the CFPC and Royal College making the exam extremely costly and redundant.  Maybe it was primarily being used as gatekeeper by some in the CFPC and Royal College.  

Removing the MCCQE2 wouldnt change the "gate keeping" step, they already have the fact that residency #s are limited to do that. Removing qe2 for the majority of situations would not change anything, other than saving alot of money for a lot of people.

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37 minutes ago, JohnGrisham said:

Removing the MCCQE2 wouldnt change the "gate keeping" step, they already have the fact that residency #s are limited to do that. Removing qe2 for the majority of situations would not change anything, other than saving alot of money for a lot of people.

I was thinking about that - but the number of practicing IMGs far exceeds the number of residency positions for IMGs.  So some IMGs must be getting licensed more directly through the colleges - it's the only way I can make sense of the numbers (e.g. <20% FM quota for IMGs but >30% FPs are IMGs). 

 But, I agree for IMGs that go through Canadian or US residency, like for CMGs, it's completely redundant.  

https://www.cihi.ca/sites/default/files/document/physicians-in-canada-report-en.pdf

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Valid point, alot of them come with their reciprocity agreements - and you don't always need to have QE1/QE2 if you have equivlanet like USMLE for american grads, but province dependent. In some provinces you can bypass qe1/2 with US training,  but go on a restricted license for a time period - but ends up just being a functional checkbox and you move on to a full license after some peer-reviewed chart review etc.

I suspect alot of the Uk/SA/Ireland ones do have both qe1/2 though, like you say, since many of them wouldn't have done residency in the US, and would need the qe1/2 checkbox to continue on (effectively also a cash grab to gain access, once their residency training is deemed equivilent with reciprocity for CCFP). 

We have CCFP, they meet requirements for it, yet still need to cash grab for LMCC. 

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I just went to take a look at the passing score and the pass rate... yikes, only 75-80% for every category combined and 85-90% for first-time CMGs, which is honestly quite puzzling for something that's only supposed to evaluate minimal competency. Guess our med schools are incompetent to the point of letting 10-15% of their cohorts graduate every year without meeting the minimum competencies of the LMCC?

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24 minutes ago, JohnGrisham said:

Valid point, alot of them come with their reciprocity agreements - and you don't always need to have QE1/QE2 if you have equivlanet like USMLE for american grads, but province dependent. In some provinces you can bypass qe1/2 with US training,  but go on a restricted license for a time period - but ends up just being a functional checkbox and you move on to a full license after some peer-reviewed chart review etc.

I suspect alot of the Uk/SA/Ireland ones do have both qe1/2 though, like you say, since many of them wouldn't have done residency in the US, and would need the qe1/2 checkbox to continue on (effectively also a cash grab to gain access, once their residency training is deemed equivilent with reciprocity for CCFP). 

We have CCFP, they meet requirements for it, yet still need to cash grab for LMCC. 

I don't disagree that it's a massively costly cash grab - but I think various other administrators could be giving tacit approval as it serves their purposes for evaluating IMGs.   

7 minutes ago, keipop said:

I just went to take a look at the passing score and the pass rate... yikes, only 75-80% for every category combined and 85-90% for first-time CMGs, which is honestly quite puzzling for something that's only supposed to evaluate minimal competency.

Having any kind of failure rate helps justify existence as 'keeping standards' - even if the original purpose was for general licensure which doesn't exist.  

Any resident not doing FM or FM-related will clearly have to put in extra work to pass an exam which is simply a costly obstacle.  And for FM it's also costly and redundant as residents have to pass the CCFP.

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31 minutes ago, indefatigable said:

Having any kind of failure rate helps justify existence as 'keeping standards' - even if the original purpose was for general licensure which doesn't exist.  

No doubt, but the pass score was being arbitrarily increased year after year — at some point (2017-2018 or something), the score needed to pass was like more than -0.6 SD away from the mean (assuming a normal distribution this would mean that 26% of the candidates would fail the exam). Heck, now the pass score is not even predetermined, it is only determined after analysis of everyone’s results (lack of transparency ++).

So, is it really about ‘keeping standards’, or is it more about ‘arbitrarily increasing the standards, in order to make sure that there’s always a small but significant percentage of candidates not meeting standards, and then using the exam’s fail rate to justify that it’s doing a good job keeping standards’ all while continuing to hike up the price of the exam year after year?

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9 hours ago, keipop said:

So, is it really about ‘keeping standards’, or is it more about ‘arbitrarily increasing the standards, in order to make sure that there’s always a small but significant percentage of candidates not meeting standards, and then using the exam’s fail rate to justify that it’s doing a good job keeping standards’ all while continuing to hike up the price of the exam year after year?

Appearance of 'keeping standards' is what matters in order to justify their continued existence - not to mention they have obvious financial self-interest in maintaining such an expensive exam.  At ~3K/CMG with ~3000 CMGs usually writing per year that's 9 Mill+ in gross revenue per year.  

For comparison, from what I understand that amount of $$$ could easily fund 40+ residency positions per year.         

In the US, there was an article in the NEJM which suggested Step 2 CS was a 'Poor Value Proposition' partly based on pass-rates (lowering pass-rates would obviously change the assumptions though). 

https://www.nejm.org/doi/full/10.1056/nejmp1213760

9 hours ago, keipop said:

No doubt, but the pass score was being arbitrarily increased year after year — at some point (2017-2018 or something), the score needed to pass was like more than -0.6 SD away from the mean (assuming a normal distribution this would mean that 26% of the candidates would fail the exam). Heck, now the pass score is not even predetermined, it is only determined after analysis of everyone’s results (lack of transparency ++).

It's a very opaque scoring system.  Prior to 2018, it was literally a very expensive check-mark for most CMGs  - with pass rates ranging from 92-99% for first timers (and for IMGs around 60 increasing to 75%).

 In 2018, they reset the scale (and passing score) which lowered the IMG and CMG pass rate to ~55-60% and 90% respectively meaning that ~1/10 CMGs wouldn't pass.  

It looks like they introduced some new scale this year before the exam was indefinitely suspended.  Unquestionably they're being very reactive - they're in a clear conflict of interest when it comes to assessing the usefulness of the exam.  

(year-round stats weren't available prior to 2019 - May had the most people writing).

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25 minutes ago, indefatigable said:

In the US, there was an article in the NEJM which suggested Step 2 CS

They've gotten rid of Step2 CS in perpetuity in the US. COVID was the triggering event but it finally brought everyone to their senses that it's absolutely useless. The only thing that keeps these examinations going is inertia. However, I personally think that the odds of QE2 being cancelled in Canada going forward are non-existent. The money is too good and they will flex every bit of their government backed muscle for our money and to stroke their own ego about the importance of their job.

Irrespective of the fact that the exams originate from a time when a medical graduates could practice as a GP without a residency, medical schools were not standardized (Flexner Report had just come out in 1910), and the test was used to make sure that the physician was competent. Now we have medical school accredition standards, residencies, and board certifications for examining competence that but they still rob us at gunpoint with a tool from the 1912. For context, Penicillin was discovered in 1928.

https://www.usmle.org/announcements/?ContentId=309

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38 minutes ago, zoxy said:

They've gotten rid of Step2 CS in perpetuity in the US. COVID was the triggering event but it finally brought everyone to their senses that it's absolutely useless. The only thing that keeps these examinations going is inertia. However, I personally think that the odds of QE2 being cancelled in Canada going forward are non-existent. The money is too good and they will flex every bit of their government backed muscle for our money and to stroke their own ego about the importance of their job.

Irrespective of the fact that the exams originate from a time when a medical graduates could practice as a GP without a residency, medical schools were not standardized (Flexner Report had just come out in 1910), and the test was used to make sure that the physician was competent. Now we have medical school accredition standards, residencies, and board certifications for examining competence that but they still rob us at gunpoint with a tool from the 1912. For context, Penicillin was discovered in 1928.

https://www.usmle.org/announcements/?ContentId=309

Yeah - I know the Step 2 CS has been discontinued.  But the modern form originated in 2004 out of a Clinical Skills Assessment that was run by the ECFMG for IMGs.

Like in Canada, the NBME was drawn by cash too.  But, the parallels don't end there as I believe the impetus that is keeping it going in Canada (besides the $$$) is the IMG licensing issue.

I pointed out the article to suggest that there was little objective rational for maintaining the Step 2 CS (before it was cancelled) - and by extension likely in Canada too.    

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19 minutes ago, indefatigable said:

But the modern form originated in 2004 out of a Clinical Skills Assessment that was run by the ECFMG for IMGs.

So CMG didn't have the QE2 before 2004? No "standardized" clinical skills assessment for CMG before that?

19 minutes ago, indefatigable said:

 But, the parallels don't end there as I believe the impetus that is keeping it going in Canada (besides the $$$) is the IMG licensing issue.

24 percent of the practising physicians in the US are IMGs. AAMC breaks down the data by specialty which is fun to look at.

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8 minutes ago, zoxy said:

So CMG didn't have the QE2 before 2004?

In the US, Step 2 CS started in 2004 - before they had a clinical exam only for IMGs run by the ECFMG. 

In Canada, the MCCQE-2 started in the early 90s at the same time as the end of the rotating internship.  One wonders if there were some political factors involved in the creation of the exam at that time.  

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Just cancel these useless tests that are just another tax on students and residents. You want to test my competency? Then make the test free. If not, stop making me pay you thousands of dollars for really absolutely nothing in return. It once made sense to have this exam, when rotating internship gave you an independent license (I do think there is an argument for this to return). Feels too much like extortion right now.

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On 6/9/2021 at 12:57 PM, zoxy said:

24 percent of the practising physicians in the US are IMGs.

It's good that the NBME did the right thing and cancelled Step 2 CS.  They have added an occupational English test (OET) that tests physician communication of IMGs - which has some rationale given that the test was originally developed in order to evaluate incoming IMGs 

Given the much more charged medico-legal environment in the US it's pretty remarkable it went through and it shows that there must a fairly high level of confidence in the updated system with no plans to go back to Step 2 CS.  

MCC promotes a single article written by a former CEO of the MCC (retired subspecialist) - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4830378/ 

The strongest point that is raised is that complaints to regulatory authorities were linked to deficient communication ability on QE2 - i.e. it has some "predictive value".  

But, that's why following the US approach makes sense!

 CMGs have consistently achieved 90-99% pass rates whereas the rate is lower for IMGs - so why not institute the OET for IMGs if this communication is the most worrying aspect (and some French equivalent in QC)?

The MCC doesn't address the out of control costs and the high fees - the QE2 costs considerably more than Step 2 CS did which was shown to be a poor financial/cost value in the US (NEJM article)!

  • for all the talk of exam and other research and development, employee travel combined office supplies was a significantly bigger budget item https://mcc.ca/media/MCC-Financial-statements-2018-2019.pdf.  
  • QE2 was the goose that laid the golden egg for the organization - it earns 12 mill for it per year- single biggest revenue earner.  
  • There's no detailed breakdown of salaries - but employees do get a nice defined benefit pension plan.  
  •  

tl;dr MCC is clearly in a conflict of interest - it's relying on the test to survive and pad its own pockets.  Unlike the NBME, I don't think it will simply discontinue the QE2 of its own volition.  

 It's under the mandate of the Medical Regulatory Authorities ( https://www.mcc.ca/news/update-on-the-mccqe-part-ii/), some kind of quasi-independent medical advocacy organization - https://fmrac.ca which doesn't look like it's too concerned with the pandemic and MCCQE that it created - I think future petitions would be better aimed at them.

Edit: Reading through the Dalhousie postgraduate communication is very positive - essentially the MCCQE2 no longer an integral part of the LMCC.  The QE2 is on hold indefinitely and it sounds like the post-graduate Deans do not believe it's necessary for residents in Canadian medical programs.  I

don't think it will come back any time soon - even though details may take more time to work out.  https://www.change.org/p/federation-of-medical-regulatory-authorities-of-canada-alternative-to-the-outdated-mccqeii-exam/u/29164222

 

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Today, we received communication that the Medical Council of Canada has decided to cease the delivery of the MCCQE Part II.

https://residentdoctors.ca/news-events/news/update-17-covid-19-and-exams/

The MCC Council has updated their criteria for obtaining the Licentiate of the Medical Council of Canada (LMCC) certificate to anyone meeting the following requirements:

  1. Are a graduate from:
    1. a medical school accredited by the Committee on Accreditation of Canadian Medical Schools or the Liaison Committee on Medical Education; or
    2. a medical school listed in one or more directories of medical schools approved from time to time by resolution and be a medical school listed in the World Directory of Medical Schools which includes a sponsor note indicating it is an acceptable medical school in Canada; or 
    3. a United States School of Osteopathic Medicine accredited by the American Osteopathic Association.
  2. Have successfully completed the MCCQE Part I (PASS)
  3. Have successfully completed:
    1. at least 12 months of acceptable clinical post graduate medical training as determined by the Executive Director; or
    2. at least 12 months of acceptable osteopathic post graduate clinical training in a program accredited by the Accreditation Council for Graduate Medical Education (ACGME) as determined by the Executive Director; and
  4.  Have the required medical credentials including verification of postgraduate training successfully source verified through MCC or, in exceptional circumstances, have provided evidence of the required medical credentials acceptable to the Executive Director. 

While the LMCC is not a licence to practise medicine many Medical Regulatory Authorities in Canada require it in order to obtain a license to practice.

I'm wondering if there is any restriction to 3 - does any PGY1 anywhere count?  Could some RC residencies be cut-down by 5 to 4 years by eliminating a completely off-service first year?

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17 hours ago, indefatigable said:

I'm wondering if there is any restriction to 3 - does any PGY1 anywhere count?  Could some RC residencies be cut-down by 5 to 4 years by eliminating a completely off-service first year?

Regardless of what the LMCC requires for certification, as they say, licensing to practice lies with the provincial colleges who make their own rules, and unlikely to deviate from "completed Royal College or College of Family Physicians certification", so it would then shift to the Royal College, which is shifting to competency by design, so it's possible that a primarily intern year might change, however, I don't think the current off-service heavy first year of residency is related to the MCCQEII, as pediatrics, at least, doesn't have any non-peds off-service.

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34 minutes ago, bearded frog said:

Regardless of what the LMCC requires for certification, as they say, licensing to practice lies with the provincial colleges who make their own rules, and unlikely to deviate from "completed Royal College or College of Family Physicians certification", so it would then shift to the Royal College, which is shifting to competency by design, so it's possible that a primarily intern year might change, however, I don't think the current off-service heavy first year of residency is related to the MCCQEII, as pediatrics, at least, doesn't have any non-peds off-service.

I've heard this referred to with respect to lab-specialties and one or two colleagues have also mentioned some dissatisfaction with the first year.  But I wonder if the word "clinical" is meant to preserve this residual "rotating" year.  Maybe CBD will also eventually change training length for some - it's a little hard to tell.  

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