Changes to US MD equivalencies - thoughts?

[Pakoon]

12 minutes ago, peace2014 said:

This is very well written, hence why LCME diverged. Canadians want to train physicians who practice medicine to serve their communities while a lot of US med schools provide physicians that serve the private sector in numerous ways. I would definitely recommend future students to consider their med schools in both countries carefully. If you just want to be a good physician, Canada should be top choice. However, Harvard or Hopkins will serve a small population of students better and will lead to rewarding careers in many other areas besides seeing patients. Which IMO are areas that are so deemphasized in Canadian schools that sometimes people don't see their values anymore cause we rely on other places to do them.... think about the vaccine development/trials, or new drugs for gene therapy, cancer

https://www.google.com/amp/s/www.theglobeandmail.com/amp/opinion/cutting-funds-for-mdphd-programs-a-blow-to-canadian-innovation/article26072106/

 

And with the government cutting funding to the MD/PhD stream it seems that the clinician scientist route will be further deemphasized ( of course PhD isn't needed to do this but I think this move speaks to the direction we are headed in).

[medigeek]

4 hours ago, bellejolie said:

i think the bigger issue is what the person below your response pointed out - we just don't have the funding. healthcare and these hospitals you are mentioning yes are excellent, but they're also private. healthcare in canada is public, for good reason with funds being controlled by the government and provinces and their priorities. its a vicious cycle, but the big schools in canada (like u of t) are rated higher and ranked more because they do more research, thereby attracting better candidates who also do those things etc etc. 

where i think we do excel in Canada, more than MGH and hopkins is patient centred care. MMIs are standard across majority of medical schools (which they are not in the states) and values such as empathy, kindness, collaboration etc are emphasized more amongst canadian schools in their selection process thereby producing less assholes than before. our medical school curricula also place high value on social determinants of health, health equity and social justice, and also tend to attract people who are interested in those things as well. in the US research/"innovation" is probably the most important thing when selecting candidates. think about our exams, vs the USMLE. there are hardly as many ethics questions as much as basic scientific details in the USMLE steps. Our OSCEs focus on the art of communication, and managing complex social situations which I would argue is far far more important to medicine than how much research a person has done. and medical schools in Canada value those things much more equally I find than in the states where research is seen as more valuable than the ability to communicate. We become much more holistic care providers which to me is "better education" than a top US school, though those values are increasingly becoming prominent there too.

to me, I think Canadian medical schools are superior. Our curricula ensure we have clinical experiences much earlier and have exposure to patient centred care. i have heard from many US staff that canadian grads are VERY well regarded tbh just because we only have 17 med schools (so to get in is already much harder), and we are hands on very fast. we also have integrated Indigenous curricula as well and overall have a different focus/priorities than the states schools. the standard is also much less variable across the 17 schools vs in the states. canadian medical license is probably one of the best to have globally, it translates to the most number of countries from what I've read and researched so I'd argue NOSM is a great medical school, please stop hating. Rural medicine is 100x harder than anything you practice in the city and the doctors that are produced there are probably smarter than i am or will ever have to be living in a city. 

What do you mean exactly by patient centred care in this context? And I'm not sure how OSCEs translate to improved patient diagnostics and treatment. I agree with your point about the research aspect though.

But when it comes to these talking points, it would be nice to hear some specific examples of how it directly affects patient care + if there's quality evidence supporting it. 

In my view, the best doctor is one who is above-average at communication but is extremely knowledgeable and is able to execute. Communication skills and navigating social issues are very important until a certain point, and at that stage it goes into diminishing returns because by definition you'd be spending far too much time. But comprehensive medical knowledge really has no limits in that sense. Though that is still different than research and innovation, which also is not super relevant to daily medical care honestly. 

[jb24]

7 hours ago, bellejolie said:

i think the bigger issue is what the person below your response pointed out - we just don't have the funding. healthcare and these hospitals you are mentioning yes are excellent, but they're also private. healthcare in canada is public, for good reason with funds being controlled by the government and provinces and their priorities. its a vicious cycle, but the big schools in canada (like u of t) are rated higher and ranked more because they do more research, thereby attracting better candidates who also do those things etc etc. 

where i think we do excel in Canada, more than MGH and hopkins is patient centred care. MMIs are standard across majority of medical schools (which they are not in the states) and values such as empathy, kindness, collaboration etc are emphasized more amongst canadian schools in their selection process thereby producing less assholes than before. our medical school curricula also place high value on social determinants of health, health equity and social justice, and also tend to attract people who are interested in those things as well. in the US research/"innovation" is probably the most important thing when selecting candidates. think about our exams, vs the USMLE. there are hardly as many ethics questions as much as basic scientific details in the USMLE steps. Our OSCEs focus on the art of communication, and managing complex social situations which I would argue is far far more important to medicine than how much research a person has done. and medical schools in Canada value those things much more equally I find than in the states where research is seen as more valuable than the ability to communicate. We become much more holistic care providers which to me is "better education" than a top US school, though those values are increasingly becoming prominent there too.

to me, I think Canadian medical schools are superior. Our curricula ensure we have clinical experiences much earlier and have exposure to patient centred care. i have heard from many US staff that canadian grads are VERY well regarded tbh just because we only have 17 med schools (so to get in is already much harder), and we are hands on very fast. we also have integrated Indigenous curricula as well and overall have a different focus/priorities than the states schools. the standard is also much less variable across the 17 schools vs in the states. canadian medical license is probably one of the best to have globally, it translates to the most number of countries from what I've read and researched so I'd argue NOSM is a great medical school, please stop hating. Rural medicine is 100x harder than anything you practice in the city and the doctors that are produced there are probably smarter than i am or will ever have to be living in a city. 

I agree with a lot of your points here except I do not feel MMI's select for good quality candidates. Ditto with the Casper nonsense we are all forced to do. Nor do contrived OSCE's with tick boxes for canned empathy statements.

I do feel all of these are easily gamed by more cunning students who can feign and answer questions in such a way that ticks the boxes. Whereas someone more gullible, who answers truly, without "looking at both sides of the issue" will be punished.

Personally, I think more diversity is needed in medical schools and MMI's select for conformity in thought, opinion, and as a result, upbringing/social class. Not to mention all the preparation courses high net worth family students have access to.

And definitely, I agree, in Canada as medical students we get far more exposure to clinical medicine than in the US (possibly because of increasing medicolegal liability in the US. Many MSI rotations in the US seem like they are shadowing instead of carrying nearly the same amount of patients as a junior resident like in Canada).

I do not think changing equivalencies in Canada is a good thing overall for our profession. We should maintain our US agreements, but sadly we are never consulted on these key administrative decisions. I don't think it has anything to do with the benefit of Canadian physicians, if anything for administrators not willing to work with the LCME.

This would be disastrous if it happened to residency equivalency.

[jb24]

On 2/7/2022 at 2:10 PM, JohnGrisham said:

They will not, as you would not be participating in the required year.

USMD is still an excellent option. You can still apply to carms under the IMG category, and who knows, you might still be favourably viewed versus carribs/other internationals.  

At the end of the day, youll be a physician, and depending on your chosen field, probably stood a better chance at getting into that program in the US anyways.

 

Applying to CaRMS as an IMG (be it Aus, Ireland, Carib, Europe, and now seemingly the US) limits specialty options to family medicine, psychiatry, and likely a few hypercompetitive internal medicine positions. You are also competing against physicians in countries like the UK and Australia that have completed some post-graduate training.

 Although you could apply to US residencies but I'm not sure of what VISA's you would need. Overall this makes going to the US a much less viable option. Terrible unilateral decision making - typical for bureaucrats in positions of power in Canadian medical education detached entirely from clinical medicine. 

 

[jb24]

On 2/7/2022 at 7:21 PM, Xbox Skully said:

Do you think usmd will look more favourable than other imgs, making it more difficult for other imgs to match in Canada.

I don't think so. US MD's generally have less clinical training and experience than their UK and Australian trained counterparts that often do a 5th year of rotating internship.

On 2/4/2022 at 10:30 AM, abcd1288 said:

 

7 figures is a lot! I wonder what those requirements that the LCME needed are. Also, I might contact my UME office to see if they have more insights

Is it really? I mean there are like 12,000 Canadian medical students roughly, even 7 figures is like an extra 800 bucks... Relative to tuition, not a huge cost IMO. I wonder what political motives might be behind such decisions.

On 2/7/2022 at 6:01 AM, ChemPetE said:

I mean USMLEs require time and money, but unless you’re aiming to kill step 1 I wouldn’t qualify them as hard. More or just an inconvenience 

I believe step 1 is going pass fail now, although step 2 is apparently the new step 1 (for needing a high score).

[UWOFTW]

6 hours ago, jb24 said:

I agree with a lot of your points here except I do not feel MMI's select for good quality candidates. Ditto with the Casper nonsense we are all forced to do. Nor do contrived OSCE's with tick boxes for canned empathy statements.

You can pass an OSCE without any medical knowledge: introduce yourself, wash your hands, ask about feelings / interests / function / expectations = PASS.

[JohnGrisham]

15 hours ago, jb24 said:

Applying to CaRMS as an IMG (be it Aus, Ireland, Carib, Europe, and now seemingly the US) limits specialty options to family medicine, psychiatry, and likely a few hypercompetitive internal medicine positions. You are also competing against physicians in countries like the UK and Australia that have completed some post-graduate training.

 Although you could apply to US residencies but I'm not sure of what VISA's you would need. Overall this makes going to the US a much less viable option. Terrible unilateral decision making - typical for bureaucrats in positions of power in Canadian medical education detached entirely from clinical medicine. 

I think you misread what i was stating.

I meant as a Canadian, who attends USMD, you are still in excellent footing. You will apply to US residencies, as has been done for decades without major concern - visas are trivial in most cases, barring specific niche circumstance. There are a large number of non-americans training on Visas in the US every year for residency, not a big deal, and the system depends on it.    Historically, even as CMG classification, the odds were even most of the USMDs ended up staying in the US for residency, rather than returning to Canada. But yes, now that its IMG status, it does limit the specific fields and spots you can apply too, no doubt this is a big blow - hence why you should be prepared to just stay in the US for residency

Not ideal but not the end of the world either(thus far based on current available information). USMD/USDO remain way ahead of all the other options for overall north american matching purposes.

 

[JohnGrisham]

10 hours ago, UWOFTW said:

You can pass an OSCE without any medical knowledge: introduce yourself, wash your hands, ask about feelings / interests / function / expectations = PASS.

haha, as someone who has marked medical school OSCES - that isn't quite accurate, but yes, those points alone do get you a decent number of points, and if you at least cover the basics of the medical piece its usually enough for most people to pass  The tricky part is when the majority of the cohort fails a station, because everyone had clear deficiencies in clinical component or misunderstood the approach (Neuro is a usual big miss!)

[JohnGrisham]

15 hours ago, jb24 said:

I don't think so. US MD's generally have less clinical training and experience than their UK and Australian trained counterparts that often do a 5th year of rotating internship.

Most of the UK and Aussie applicants are trying to match back before they do any foundation year training, so thats not accurate. But yes, many who end up not matching go onto doing some foundational year training to continue to build skills and beef up their application.

That said, at an exiting medical school comptency level for clinical skills and functioning in a hospital setting, they are comparable (from the sample size I have had). I'd still put both at usually being less ready to go at the start of PGY1 compared to CMGs.  CMGs get significantly more freedom to be independent and build skills and functionality during m3/m4. The Irish/aussie/uk grads that do match without minimal post-grad training from abroad usually take the first 6 months to get up to speed due to the steep learning curve. But they all mostly do fine and are great afterwards. PGY1 is just extra rough and hellish for them. 

[bearded frog]

21 hours ago, jb24 said:

I don't think so. US MD's generally have less clinical training and experience than their UK and Australian trained counterparts that often do a 5th year of rotating internship.

USMD admission requirements are significantly higher, with standards that at least immediately after the schism will be the same as Canadian, and I think would still be looked at favourably vs current IMG schools.

[Edict]

On 2/16/2022 at 8:08 PM, bellejolie said:

i think the bigger issue is what the person below your response pointed out - we just don't have the funding. healthcare and these hospitals you are mentioning yes are excellent, but they're also private. healthcare in canada is public, for good reason with funds being controlled by the government and provinces and their priorities. its a vicious cycle, but the big schools in canada (like u of t) are rated higher and ranked more because they do more research, thereby attracting better candidates who also do those things etc etc. 

where i think we do excel in Canada, more than MGH and hopkins is patient centred care. MMIs are standard across majority of medical schools (which they are not in the states) and values such as empathy, kindness, collaboration etc are emphasized more amongst canadian schools in their selection process thereby producing less assholes than before. our medical school curricula also place high value on social determinants of health, health equity and social justice, and also tend to attract people who are interested in those things as well. in the US research/"innovation" is probably the most important thing when selecting candidates. think about our exams, vs the USMLE. there are hardly as many ethics questions as much as basic scientific details in the USMLE steps. Our OSCEs focus on the art of communication, and managing complex social situations which I would argue is far far more important to medicine than how much research a person has done. and medical schools in Canada value those things much more equally I find than in the states where research is seen as more valuable than the ability to communicate. We become much more holistic care providers which to me is "better education" than a top US school, though those values are increasingly becoming prominent there too.

to me, I think Canadian medical schools are superior. Our curricula ensure we have clinical experiences much earlier and have exposure to patient centred care. i have heard from many US staff that canadian grads are VERY well regarded tbh just because we only have 17 med schools (so to get in is already much harder), and we are hands on very fast. we also have integrated Indigenous curricula as well and overall have a different focus/priorities than the states schools. the standard is also much less variable across the 17 schools vs in the states. canadian medical license is probably one of the best to have globally, it translates to the most number of countries from what I've read and researched so I'd argue NOSM is a great medical school, please stop hating. Rural medicine is 100x harder than anything you practice in the city and the doctors that are produced there are probably smarter than i am or will ever have to be living in a city. 

I'd argue our healthcare system does not prioritize patients at all. Its not our training or our fault as physicians, but the incentive structure is not there. 

Patients wait months to see a doctor in Canada, especially a specialist. Wait times for surgeries are long, and there is no incentive for patient satisfaction here. Canadians are a captive tax-paying population that has nowhere else to get healthcare, there is simply no incentive to make them happy beyond the bare minimum to keep them tolerant but disgruntled. 

Just comparing to the US, patient satisfaction is important in the US, hospitals want to make sure patients are happy in order to generate more revenue and have leverage when negotiating with insurers. At wealthy US hospitals, staffing is much better, and healthcare staff are paid more, patients are given surveys at the end of their hospital visit/stay and these surveys are used to improve satisfaction. While Canada's healthcare does many things right, the aspect of patient satisfaction is one area that it isn't great at. 

I've been a resident covering wards of 40-50 patients with up to 14 traumas/consults overnight and up to 7 ORs with just a senior who is mostly in the OR. That kind of staffing just doesn't exist in the US. No amount of MMIs and ethical questions could change the fact that I told people who had waited 7 hours to see a resident in ER that I was going to have to step out for a trauma and might be back in an hour or more. Neither was this training useful when I told a patient that their surgery was going to be pushed back to the next day for 3 days in a row because our service shared just one acute surgery OR with 4 other surgical services. Maybe it helped a bit as I tried managing an angry son who told me he was a cop and threatened to sue our hospital for our delays in care. 

Just goes to show you, teachings in school are one thing, but real life is another, and how your health system is structured makes a huge difference in the care you can offer. 

 

 

[Bobthebuilder]

50 minutes ago, Edict said:

<<Just comparing to the US, patient satisfaction is important in the US, hospitals want to make sure patients are happy in order to generate more revenue and have leverage when negotiating with insurers. At wealthy US hospitals, staffing is much better, and healthcare staff are paid more, patients are given surveys at the end of their hospital visit/stay and these surveys are used to improve satisfaction. While Canada's healthcare does many things right, the aspect of patient satisfaction is one area that it isn't great at. >>

Patients who die cause they can't access insulin don't complain. Dat is true. 

 

**I kid**I kid**flies away**

[jb24]

On 2/17/2022 at 4:42 PM, JohnGrisham said:

Most of the UK and Aussie applicants are trying to match back before they do any foundation year training, so thats not accurate. But yes, many who end up not matching go onto doing some foundational year training to continue to build skills and beef up their application.

That said, at an exiting medical school comptency level for clinical skills and functioning in a hospital setting, they are comparable (from the sample size I have had). I'd still put both at usually being less ready to go at the start of PGY1 compared to CMGs.  CMGs get significantly more freedom to be independent and build skills and functionality during m3/m4. The Irish/aussie/uk grads that do match without minimal post-grad training from abroad usually take the first 6 months to get up to speed due to the steep learning curve. But they all mostly do fine and are great afterwards. PGY1 is just extra rough and hellish for them. 

I agree CMG's generally have the most clinical exposure relative to other areas. Definitely more than the USMD in which clerkship is often glorified shadowing.

 

[frankg]

When I read about this change tonight, I could not believe it. It saddens me. Whoever initiated this change seems to be short-sighted, given that it would be much harder to re-couple once the LCME-CACMS relationship is de-coupled after decades of tradition. But it might be the case that the LCME-CACMS relationship has been too difficult to maintain. In any case, the lack of discussion in the Canadian medicalcommunity about this change is concerning. We should at least have the opportunity to express our thoughts in this important matter.

I found this LCME document prior to this change, which described the history of LCME in Canada. Might be a good read (starting from page 198).

https://www.lcme.org/wp-content/uploads/filebase/articles/October-2017-The-75-Year-History-of-the-LCME_COLOR.pdf

The best case scenario is that CACMS accreditation continues to be recognized by individual state medical boards as equivalent to LCME accreditation, as in the equivalent recognition of RCPSC/CFPC certifications despite the lack of mutual accreditation of residency programs (earlier discussions suggested that Canadian residency programs were accredited by ACGME, which is not true). The rationale would be to maintain the close and unique reciprocity of Canadian/US medical qualifications, but it may become an opportunity for at least some U.S. states to treat Canada as "others" given the current world political environment. The impact will be seen in the next few years.