Unmatched to First Choice Specialty in Year 2 and Backing Up

[Monkey D. Luffy]

1 hour ago, SpeakWhite said:

By the way, no one cares about personal statements because they are the same for all applicants.

This is wildly untrue, at least at my program. The personal statement is extremely important and definitely differs between applicants.

[Specialty]

1 hour ago, SpeakWhite said:

And what sort of standardized testing would you suggest? Are there any that are validated to predict success is residency? How would you apply it to small programs with few applicants? What about bias (e.g. towards those with a first language other than English, for standardized tests in English)? I think it would be very unwise for a program to rely on standardized testing to choose a trainee when fit and personality have a much greater impact on success in a given environment.

By the way, no one cares about personal statements because they are the same for all applicants.

I have a suggestion for a cheaper system that is perfectly fair: random assignment of residency positions.

 

Lmao- im not saying standardized testing is a better predictor of success in residency, but it certainly is WELL CORRELATED to sheer hard work and # of hours dedicated, so it will atleast reward the person who worked harder to get the spot that they deserved. At the end of the day, all us canadian medical graduates are going to become doctors in one specialty vs another, so atleast reward the ones who put in more time and effort studyig to get their first specialty preference.

The language thing u mentioned is irrelevant for CMGs. This isn't a william shakespeare contest, this would be a knowledge test like the USMLEs. Once again, personalities should be screened out for with obvious red flags, but past that, we are terribly bad at teasing out who has good personalities based on limited elective time, especially when some people just have nicer reference letter writers than others in terms of how much they hype you up. There's also so many more biases with personalties, such that the "bubblier, more handsome/hot/outgoing" candidate is perceived as being better.

It's funny whenever the topic of removing standardized testing is mentioned, whether that's residency or the MCAT, the alternative is some liberal bs like "lets evalute ppl holistically", which ends up opening the door to way more BS/nepotism/fraud/luck, where everyone just makes up essays on how marginalized they are, has their family friends write their reference letters, etc.

[zxcccxz]

4 hours ago, SpeakWhite said:

And what sort of standardized testing would you suggest? Are there any that are validated to predict success is residency? How would you apply it to small programs with few applicants? What about bias (e.g. towards those with a first language other than English, for standardized tests in English)? I think it would be very unwise for a program to rely on standardized testing to choose a trainee when fit and personality have a much greater impact on success in a given environment.

By the way, no one cares about personal statements because they are the same for all applicants.

I have a suggestion for a cheaper system that is perfectly fair: random assignment of residency positions.

 

While I do agree that standardized testing as the primary selection factor sucks for the reasons mentioned, I think the idea that "fit and personality" are any better is an overstatement. More often than not what "fit" ends up meaning is selecting applicants who are exactly like the residents already in the program - in medicine as a whole this has traditionally meant wealthy, caucasian males who are 3rd generation doctors. When intangible measures such as "fit" are emphasized, it also creates a simple means of justifying the unfair exclusion certain individuals - i.e., we ranked Candidate X lower than Candidate Y because they weren't as good of a "fit", not because Candidate Y's parent is a bigshot faculty member with a lot of pull in residency selections. Same thing with personality - I mean, do we really need more "Ortho bros" or do you really need to have self-labeled ADHD and an obsession with hiking/mountain biking to be a successful emergency resident/doctor? Sure, some of this is self-selecting, but a lot of it is also a direct result of the emphasis on "fit".

Ultimately this sort of thinking trickles down into poorer patient care because the physicians we train are so far removed from the patient populations that they serve. It's nice to see a greater emphasis on diversity in medicine these days, but I've found that a lot of it is tokenism. Medical schools and programs just want to say that their cohorts are "diverse", without a genuine desire to appreciate what that means.

[SpeakWhite]

1 hour ago, Specialty said:

Lmao- im not saying standardized testing is a better predictor of success in residency, but it certainly is WELL CORRELATED to sheer hard work and # of hours dedicated, so it will atleast reward the person who worked harder to get the spot that they deserved. At the end of the day, all us canadian medical graduates are going to become doctors in one specialty vs another, so atleast reward the ones who put in more time and effort studyig to get their first specialty preference.

The language thing u mentioned is irrelevant for CMGs. This isn't a william shakespeare contest, this would be a knowledge test like the USMLEs. Once again, personalities should be screened out for with obvious red flags, but past that, we are terribly bad at teasing out who has good personalities based on limited elective time, especially when some people just have nicer reference letter writers than others in terms of how much they hype you up. There's also so many more biases with personalties, such that the "bubblier, more handsome/hot/outgoing" candidate is perceived as being better.

It's funny whenever the topic of removing standardized testing is mentioned, whether that's residency or the MCAT, the alternative is some liberal bs like "lets evalute ppl holistically", which ends up opening the door to way more BS/nepotism/fraud/luck, where everyone just makes up essays on how marginalized they are, has their family friends write their reference letters, etc.

I think you're wrong about standardized testing exam results correlating well with hard work and hours invested. Take the MCCQE1 - it's a medical knowledge exam IMGs grind hard for, yet consistently get worse results than CMGs. And this is probably precisely the type of exam you seem to want to predicate residency program ranklists on.

Second, if you asked 100 residency programs if they'd prefer to have a resident who scored 270 on MCCQE1 but is difficult to teach and does not generally get along well with others without it being a "red flag", or someone who scored 260 but has a personality better suited to being mentored - I think 95 of them would prefer the latter. If carefully choosing the right person to work with you everyday for the next 5 years on the basis of a holistic assessment is "liberal bs", please count me in as a liberal bs enabler.

Also, matching to a preferred specialty is not a "reward". Residency training is not a karmic present for hard workers.

1 minute ago, zxcccxz said:

While I do agree that standardized testing as the primary selection factor sucks for the reasons mentioned, I think the idea that "fit and personality" are any better is an overstatement. More often than not what "fit" ends up meaning is selecting applicants who are exactly like the applicants already in the program - in medicine as a whole this has traditionally meant been wealthy, caucasian males who are 3rd generation doctors. When intangible measures such as "fit" are emphasized, it also allows for the unfair exclusion of candidate - i.e., we ranked Candidate X lower than Candidate Y because they weren't as good of a "fit", not because Candidate Y's parent is a bigshot faculty member with a lot of pull in residency selections. Same thing with personality - I mean, do we really need more "Ortho bros" or do you really need to have self-labeled ADHD and an obsession with hiking/mountain biking to be a successful emergency resident/doctor? Sure, some of this is self-selecting, but a lot of it is also a direct result of the emphasis on "fit".

Ultimately this sort of thinking trickles down into poorer patient care because the physicians we train are so far removed from the patient populations that they serve. It's nice to see a greater emphasis on diversity in medicine these days, but I've found that a lot of it is tokenism. Medical schools and programs just want to say that their cohorts are "diverse", without a genuine desire to appreciate what that means.

Of course there is a lot of bias. But relying on standardized testing will just shift the bias around (towards applicants with better exam-taking skills, which does not translate to better patient care).

So let me submit my proposal to you again, why not assign residency positions randomly? It is unbiased and will instantly get rid of nepotism.

[ByeQuebec]

1 hour ago, Specialty said:

Lmao- im not saying standardized testing is a better predictor of success in residency, but it certainly is WELL CORRELATED to sheer hard work and # of hours dedicated, so it will atleast reward the person who worked harder to get the spot that they deserved. At the end of the day, all us canadian medical graduates are going to become doctors in one specialty vs another, so atleast reward the ones who put in more time and effort studyig to get their first specialty preference.

The language thing u mentioned is irrelevant for CMGs. This isn't a william shakespeare contest, this would be a knowledge test like the USMLEs. Once again, personalities should be screened out for with obvious red flags, but past that, we are terribly bad at teasing out who has good personalities based on limited elective time, especially when some people just have nicer reference letter writers than others in terms of how much they hype you up. There's also so many more biases with personalties, such that the "bubblier, more handsome/hot/outgoing" candidate is perceived as being better.

It's funny whenever the topic of removing standardized testing is mentioned, whether that's residency or the MCAT, the alternative is some liberal bs like "lets evalute ppl holistically", which ends up opening the door to way more BS/nepotism/fraud/luck, where everyone just makes up essays on how marginalized they are, has their family friends write their reference letters, etc.

Finally, someone who's not afraid to spill the truth. Deep down, we know this process is utter BS. I can't believe that the US has decided to remove the step 1 score. It's the most anti-american dream thing they could have done. The decision to remove LCME accreditation for canadian med schools is also a threat to canadian doctors as we are very close to being at the mercy of local politicians. Canadian physicians should fight for every inch of their autonomy very vocally.

[ByeQuebec]

Most of the promising ''star'' future residents with glowing letters I met ended up being lazy, toxic and petty people.

[SpeakWhite]

1 minute ago, ByeQuebec said:

Most of the promising ''star'' future residents with glowing letters I met ended up being lazy, toxic and petty people.

So you'd be in favor of a holistic assessment that looks beyond letters of reference and standardized exam scores to make sure lazy, toxic and petty people aren't picked?

[ByeQuebec]

There needs to be emphasis on standardized exam scores. Our profession is first and foremost a science. The reason we can justify being paid as much as we do is because of the extensive background of basic and clinical sciences that we can integrate for our patients. This is what separates us from others and guides our management of patients. Anyone who denies that in-training residency exams or MCCQE part 1 do not correlate with clinical acumen is lying to themselves. The current residency matching process completely lacks this evaluation. Of course, being receptive to feedback is central to our profession as well, and can never be fully evaluated apart from in-depth review of LORs, MSPR, and electives, which programs already do. We are training Carmslogists instead of medical doctors. 

[SpeakWhite]

Just now, ByeQuebec said:

There needs to be emphasis on standardized exam scores. Our profession is first and foremost a science. The reason we can justify being paid as much as we do is because of the extensive background of basic and clinical sciences that we can integrate for our patients. This is what separates us from others and guides our management of patients. Anyone who denies that in-training residency exams or MCCQE part 1 do not correlate with clinical acumen is lying to themselves. The current residency matching process completely lacks this evaluation. Of course, being receptive to feedback is central to our profession as well, and can never be fully evaluated apart from in-depth review of LORs, MSPR, and electives, which programs already do. We are training Carmslogists instead of medical doctors. 

Medicine is first and foremost a social profession. Don't get me wrong, science is central to medicine as well, but the "best" physicians who make the biggest difference in the lives of their patients and are the most appreciated are family physicians with exceptional interpersonal skills.

Physicians get paid as much as they do because we have the most powerful unions in the country and aren't afraid to wield that power. PhDs + postdocs with as many years of training and a better background of basic and clinical science make far less money.

The only published evidence (by the MCC itself) regarding the MCCQE1 is that the lowest scorers get more complaints against them (and guess what - they're still licensed physicians that see patients independently!) And the vast majojrity of in-training exams are not standardized.

Why does it matter if residency programs aren't assigned on the basis of clinical acumen? All graduating med students in Canada have a pathway to licensure and independent practice, so the ultimate set of physicians that are treating the population isn't changing no matter how you shuffle the residency seats around.

[ByeQuebec]

I fully respect your opinion that medicine is a social profession.

Our ''unions'', on the contrary, are extremely weak. They are loosely organized associations rather than unions, with very weak bargaining power. Our only bargaining power with governments is our ability to be licensed in the USA, which is actively threatened due to different ongoing Canadian and American issues. The few specialties who have already lost this privilege are the ones who have ongoing severe issues with unemployment and never ending fellowships/PHDs. 

[Sceptical]

3 hours ago, SpeakWhite said:

And what sort of standardized testing would you suggest? Are there any that are validated to predict success is residency? How would you apply it to small programs with few applicants? What about bias (e.g. towards those with a first language other than English, for standardized tests in English)? I think it would be very unwise for a program to rely on standardized testing to choose a trainee when fit and personality have a much greater impact on success in a given environment.

By the way, no one cares about personal statements because they are the same for all applicants.

I have a suggestion for a cheaper system that is perfectly fair: random assignment of residency positions.

 

I noticed that we started addressing this individual's points except the very last one. My apologies for perhaps sounding flippant or possibly "feeding the troll", but why don't we consider sortition as a legitimate means for residency training selection? Having experience on the other side of the MD admissions process, once med school applicants attain whichever parameters we decide on (e.g. GPA, MCAT scores, interview scores, CASPer, etc.), is the remainder of the selection process any different from or superior to random selection? This would indeed simplify the process and minimize the contribution of nepotism to the equation. 

[SpeakWhite]

14 minutes ago, ByeQuebec said:

I fully respect your opinion that medicine is a social profession.

Our ''unions'', on the contrary, are extremely weak. They are loosely organized associations rather than unions, with very weak bargaining power. Our only bargaining power with governments is our ability to be licensed in the USA, which is actively threatened due to different ongoing Canadian and American issues. The few specialties who have already lost this privilege are the ones who have ongoing severe issues with unemployment and never ending fellowships/PHDs. 

No, our unions are in fact extremely strong, which is why Canada has much lower numbers of physicians per capita than many comparable countries in Western Europe due to extensive gatekeeping, and which is also why Canadian physicians are amongst the best paid in the world relative to median income. I can't count the number of health care system reforms that have been effectively throttled by physician union interventions.

 

16 minutes ago, Sceptical said:

I noticed that we started addressing this individual's points except the very last one. My apologies for perhaps sounding flippant or possibly "feeding the troll", but why don't we consider sortition as a legitimate means for residency training selection? Having experience on the other side of the MD admissions process, once med school applicants attain whichever parameters we decide on (e.g. GPA, MCAT scores, interview scores, CASPer, etc.), is the remainder of the selection process any different from or superior to random selection? This would indeed simplify the process and minimize the contribution of nepotism to the equation. 

If everyone getting into med school knew they were going to match to residency randomly, they would be encouraged to learn much more broadly and focus less on CV-stuffing, ass-kissing and ego-boosting. Medicine would attract a lot fewer of the typical Premed101 forum posters, and instead a lot more academically strong but flexible students better adapted to changing population needs.

[Alimali]

34 minutes ago, SpeakWhite said:

Medicine is first and foremost a social profession. Don't get me wrong, science is central to medicine as well, but the "best" physicians who make the biggest difference in the lives of their patients and are the most appreciated are family physicians with exceptional interpersonal skills.

Physicians get paid as much as they do because we have the most powerful unions in the country and aren't afraid to wield that power. PhDs + postdocs with as many years of training and a better background of basic and clinical science make far less money.

The only published evidence (by the MCC itself) regarding the MCCQE1 is that the lowest scorers get more complaints against them (and guess what - they're still licensed physicians that see patients independently!) And the vast majojrity of in-training exams are not standardized.

Why does it matter if residency programs aren't assigned on the basis of clinical acumen? All graduating med students in Canada have a pathway to licensure and independent practice, so the ultimate set of physicians that are treating the population isn't changing no matter how you shuffle the residency seats around.

No, the reason we are paid well is not simply because of unions. It is because we have the most skilled, intelligent, and hard-working people entering this field out of high school with the highest grades. It is a profession that no average Joe from the street could perform. This nicheness and irreplace-ability of physicians is what dictates our high pay - basic supply and demand. Unfortunately, once you liberalize this field, remove metrics of meritocracy, and decrease physician pay, those top 1-2% students in high schools will no longer be motivated to enter medicine, and will enter other lucrative fields such as finance, software engineering, etc. Sure, you might have people who are "better intentioned" entering these fields, but being a nice person isn't good enough for an average Barista to be able to manage heart failure, nephrotic syndrome, and diabetic ketoacidosis at the same time while on a busy 24-hour call.

Also, your statement of a person with a "270 on MCCQE1 but is difficult to teach and does not generally get along well with others" is a weak argument. They already mentioned screening out red flags, and someone who is "difficult to teach" will most definitely get screened out of the process. You clearly have not been on the admissions committees of any of these competitive specialties, cause the top 60% of students' reference letters are all great/claim their students are amazing, leaving little value to be gained from the reference letter.

Also the MCCQE is dogsh*t easy. Scored very high with minimal studying. Nothing special about being a Canadian that predisposes you to doing well on it. Those IMGs failing the test are the same ones who couldn't score well on the MCAT and decided to go to the carribean instead for an easy way back. 

[SpeakWhite]

7 minutes ago, Alimali said:

Also the MCCQE is dogsh*t easy. Scored very high with minimal studying. Nothing special about being a Canadian that predisposes you to doing well on it. Those IMGs failing the test are the same ones who couldn't score well on the MCAT and decided to go to the carribean instead for an easy way back. 

Good, so you agree with me that the standardized test available for the other posters who dislike "holistic" admissions processes is garbage and does not at all reflect hard work.

edit: most IMGs are not Canadians studying abroad but MDs with extensive practice experience, by the way.

Quote

It is because we have the most skilled, intelligent, and hard-working people entering this field out of high school with the highest grades.

It's impossible to spend 5 minutes on this forum and hold this opinion sincerely.

Quote

basic supply and demand

Yes, because the supply is artifically kept low while the demand grows, not because physicians are God's chosen to lead the plebs and make bank. For every successful med school acceptee, there are 8 applicants who could have been just as good.

Quote

You clearly have not been on the admissions committees of any of these competitive specialties, cause the top 60% of students' reference letters are all great/claim their students are amazing, leaving little value to be gained from the reference letter.

Perhaps you haven't either, because the number is closer to 100%, and this is also why LRs are of almost no use, just the same as personal statements.

Edited March 30, 2023 by SpeakWhite

[Alimali]

1 minute ago, SpeakWhite said:

Yes, because the supply is artifically kept low while the demand grows, not because physicians God's chosen to lead the plebs and make bank. For every successful med school acceptee, there are 8 applicants who could have been just as good.

Well, to be fair, the "free market value" of the services we provide has been kept artificially low too. A goddamn locksmith nowadays is allowed to charge 300$ to provide you with a spare house key in the middle of the night, whereas our life-changing, and often life-saving surgical procedures somtimes only nets us 500$ post overhead?  In what fricking world is that fair? There is a huge mismatch between the value of the services we provide and how much we get paid? 

Also doctors in every country are among the highest paid relative to the median income. you can't say doctors in canada are paid better than doctors in India, Ghana, Pakistan, etc., because in those countries their doctors are also in the top 1% income percentile relative to the population/COL. The only exception is some european countries, where they still get pensions/decreased length of training to compensate for their shortfall, and we can see how great that's going for them in the UK right now..... haha.

We have a limited provincial budget my friend. We can't provide everyone with their own personal one-on-one therapist, and infinite healthcare resources. These all come at the expense of physician/worker's income, and in this day and age where software engineers are getting Sweet deals from companies to work 3 days a week from home, we are going to witness a huge brain drain in field of medicine...having the smartest ppl enter other fields,...something I fear deeply for our kids

[unmatched2022]

4 minutes ago, SpeakWhite said:

It's impossible to spend 5 minutes on this forum and hold this opinion sincerely.

Hahahahahaha, well said.

The point about random sorting is valid. Let's play a thought experiment:

You go to the gas station or convenience store and buy a lottery ticket. You select some numbers at random.

Outcome 1: You win the lottery.

• You celebrate, enjoy yourself, have a good time.
• Do you commend your skill for selecting those numbers, or do you admit you got lucky?

Outcome 2: You lose the lottery.

• You feel bad (maybe?) and go on with your life.
• You don't: feel less than anyone else for not guessing the right numbers correctly, something which is so unlikely it's nearly impossible.

This is the case for many residency positions at this point, to the point where it's only those sure-shot advantages (i.e., nepotism) that are 1:1 to get you into a residency position.

[SpeakWhite]

1 minute ago, unmatched2022 said:

Hahahahahaha, well said.

The point about random sorting is valid. Let's play a thought experiment:

You go to the gas station or convenience store and buy a lottery ticket. You select some numbers at random.

Outcome 1: You win the lottery.

• You celebrate, enjoy yourself, have a good time.
• Do you commend your skill for selecting those numbers, or do you admit you got lucky?

Outcome 2: You lose the lottery.

• You feel bad (maybe?) and go on with your life.
• You don't: feel less than anyone else for not guessing the right numbers correctly, something which is so unlikely it's nearly impossible.

This is the case for many residency positions at this point, to the point where it's only those sure-shot advantages (i.e., nepotism) that are 1:1 to get you into a residency position.

So since it's already a lottery with the exception of nepotism, why not go all the way and make it a true lottery? No more nepotism that way.

Many possible implementations: everyone submits a ranklist, and candidates are drawn one by one and given their top still available choice (or a random seat if their list ran out). Or just go full RNG.

[Sceptical]

7 minutes ago, unmatched2022 said:

Hahahahahaha, well said.

The point about random sorting is valid. Let's play a thought experiment:

You go to the gas station or convenience store and buy a lottery ticket. You select some numbers at random.

Outcome 1: You win the lottery.

• You celebrate, enjoy yourself, have a good time.
• Do you commend your skill for selecting those numbers, or do you admit you got lucky?

Outcome 2: You lose the lottery.

• You feel bad (maybe?) and go on with your life.
• You don't: feel less than anyone else for not guessing the right numbers correctly, something which is so unlikely it's nearly impossible.

This is the case for many residency positions at this point, to the point where it's only those sure-shot advantages (i.e., nepotism) that are 1:1 to get you into a residency position.

So would you think it fair that once a CARMS applicant meets a certain threshold (whether is # of weeks rotating in the target specialty, # of research projects in the same specialty, no academic red flags/holds, etc.), the remainder should be explicitly left up to chance to decide? Given the decreasing interest in FM as a career, the selection process of many specialty residency training programs sure is starting to feel like that (and perhaps worse in the future) given the sheer # of applicants being routed to non-FM specialties, I presume.

Edit: spelling

[unmatched2022]

@Sceptical I'm not entirely sure. I don't think this would be fair either, but I think at the moment we are indirectly a lottery-based system. I am not even saying we need a change to the system, but there needs to be some transparency. At minimum telling applicants their paper score vs. their interview score would be one way for them to consider improving their application(s) if they try again. Beyond that, it is also a learning lesson - they can learn where they're deficient so that the next time they have a do-or-die career decision on the line, they come more prepared.

Regardless, I don't think anyone here believes our current system works.

[SpeakWhite]

1 minute ago, unmatched2022 said:

I don't think this would be fair either

It is literally the only perfectly fair system - everyone gets the same chance.

[SpeakWhite]

12 minutes ago, Alimali said:

Well, to be fair, the "free market value" of the services we provide has been kept artificially low too

The preconditions to a "free market" do not exist in healthcare.

Quote

In what fricking world is that fair?

If you believe in the "free market", the current price is always the fair price.

Quote

These all come at the expense of physician/worker's income

That actually sounds like a great idea. I wonder what "free market" solutions could be used to achieve such a goal.

Quote

we are going to witness a huge brain drain in field of medicine...having the smartest ppl enter other fields,...something I fear deeply for our kids

Sounds good, I'll wait.

[Findanus]

1 hour ago, SpeakWhite said:

It is literally the only perfectly fair system - everyone gets the same chance.

You're right.

A possible meet in the middle compromise would be the following:

 

1. Return of the rotating internship with every graduating medical student becoming a family doctor.

2. A lottery system for any currently practicing physician to re-enter in their field of choice. For instance, if 100 FPs want to apply for 10 anesthesiology spots, then a random 10 will get them. If 3 people want to apply to the 10 medical microbiology spots, all will get them. Maybe there's a way to select for location preference too so that one isn't included in lottery draws at certain locations they don't want.

The more I think about it the more I feel like a lottery isn't a bad idea. It would solve the problem of family inheritance of specialist positions.

[Guest2020_]

5 hours ago, Specialty said:

It's funny whenever the topic of removing standardized testing is mentioned, whether that's residency or the MCAT, the alternative is some liberal bs like "lets evalute ppl holistically", which ends up opening the door to way more BS/nepotism/fraud/luck, where everyone just makes up essays on how marginalized they are, has their family friends write their reference letters, etc.

Coincidentally a lot of the same people that push this narrative are those who stand to benefit from pre-existing connections and networks and the elimination of standardized testing. I've never met someone with limited connections/first gen in medicine actually complain that standardized testing prevented them from making it to med school or beyond... in fact it's been the opposite

[Sceptical]

9 hours ago, Guest2020_ said:

Coincidentally a lot of the same people that push this narrative are those who stand to benefit from pre-existing connections and networks and the elimination of standardized testing. I've never met someone with limited connections/first gen in medicine actually complain that standardized testing prevented them from making it to med school or beyond... in fact it's been the opposite

It probably doesn't matter which rules or restrictions we put into place, because those with the most resources (wealth, connections/"legacy", even fraud), will be the first to find the path of least resistance to attain the goal of being selected, whether in MD admissions or through CARMS. Standardized testing can be an equalizer, however the more resources you have, the more you can pour into exam prep and the better placed you are to weather other life events/crises coming your way. Wealth can also allow one to apply more broadly and travel to interviews. Personal statements can be written by paid ghostwriters (although AI might put a dent to this). Geographic restrictions (esp. in the context of MD admissions) can be overcome by having the resources to move to specific parts of the country to optimize in-province statuses. Diversity streams (e.g. black applicants, indigenous applicants) are vulnerable to potential fraud as can be shown recently in academia with professors/administrators being outed for outright or borderline fraudulent indigenous identity claims - but only after decades in successful careers. It will always be a challenge to find and train physicians that resemble their patient population - with the possible exception being IMG (non-CSA) physicians. Interestingly, I have yet to see folks "gaming" the system on the basis of language requirements, but maybe @SpeakWhite is better placed to comment on this. 

[unmatched2022]

I'm very happy with the way this thread has gone. I think the important thing is to document this for future classes of pre-meds and med students to realize where and how the system goes awry. There was likely a time in which medical admissions were primarily based around criteria that could be very easily manipulated (being the son of the Dean or knowing the right people), but at some point that culture was changed. There is still manipulation around medicine admissions of course, but there is at least some level of oversight and accountability that is simply lacking in residency admissions, even in specialties that have more spaces (internal medicine comes to mind even).

I wonder as well if decisions that are politically palatable benefit the decision makers in the short term, but are not considered or reviewed in the long term. The elective cap made sense at the time of its introduction, but did it make sense with COVID, when no one could do visiting electives anyways? Has it made IM and FM significantly more competitive as people now reasonably "back up" into the specialties while then displacing those who wanted to do these specialties to begin with? Why were visiting electives blocked through 2022-2023? I just don't know who makes these decisions, and if people are genuinely reviewing these policies to see if they make sense after a certain amount of time has passed. Did someone review the decision to remove the rotating internship and see if it actually improved things? Who are the political overlords dictating your career trajectories, and are they thinking twice about their impacts?