CaRMS 2023-Second Iteration

[SpeakWhite]

25 minutes ago, Andrew said:

He assumes that any immigrant to Canada should have full privileges of a natural born Canadian and gets upset when that's not the case. (let's be honest, 99% of the time Canadian immigrants DO have the full privileges and no country on Earth gives their immigrants 100% privilege).

There is no such distinction in Canadian employment law as a "natural-born citizen". This is an American idea.

That being said, IMGs who want to apply to streams where they can compete with CMGs can do so in Québec, where there were 99 unfilled family medicine positions after the R-1 1st iteration.

The system for residency admission in Canada is probably one of the fairest in the world. The only way to make it fairer would be to assign positions randomly, but such a system would likely have to totally exclude IMGs until all CMGs are matched.

[Andrew]

39 minutes ago, SpeakWhite said:

There is no such distinction in Canadian employment law as a "natural-born citizen". This is an American idea.

That being said, IMGs who want to apply to streams where they can compete with CMGs can do so in Québec, where there were 99 unfilled family medicine positions after the R-1 1st iteration.

The system for residency admission in Canada is probably one of the fairest in the world. The only way to make it fairer would be to assign positions randomly, but such a system would likely have to totally exclude IMGs until all CMGs are matched.

You're taking a tiny portion my line of reasoning out of context. You need to go back and re-read the entire thread and the "ideas" (I'll use that term loosely) posted by Samic1988 and Imghope. Essentially, he's an IMG complaining that the CaRMS matching doesn't treat CMGs, CSAs and IMGs equally. We don't have to specifically use the term Natural Born Citizen, Protectionism is another general term for this. It doesn't really matter what label we put on this, because most if not all countries in the world have some element of this written into their laws or institutional policies (and we can see CaRMs as an actual example of this).

The general idea, is that most countries support something that was born, trained, manufactured etc. locally first, before relying on foreign-produced or trained goods/people.

Using this line of reasoning, a CMG is locally born, raised, educated up to and including medical school (and even subsidized by Canadian taxpayers who want a return on their tax dollars).

A CSA is a locally born, raised, educated up to usually undergrad and then foreign trained (usually in Commonwealth country e.g. Ireland, Australia).

An IMG is a foreign born, foreign raised, foreign educated up to undergrad and foreign educated in medical school.

Most people worldwide support "Made in Canada (or wherever)"

[indefatigable]

5 hours ago, Edict said:

Agree with the points here and interesting study but I have some concerns about the way they defined CSA and IMG. It sounds like they defined IMGs as non-citizen/PR and not born in Canada, but that captures visa trainees who are mostly funded by their home governments (Saudi/other ME trainees) not the immigrant IMGs most of us are speaking about who applied through CaRMS.

Immigrant IMGs would have obtained their citizenships or PR before applying for IMG spots in CaRMS and would be classified as CSA/non-Western in this dataset. Important to know. 

This is important when you look at retention rates, visa trainees may be mandated to go home after their training. Unfortunately, you need to read the fine print these days, can't even trust the literature. 

Thanks for looking at this more carefully!

Visa trainees could definitely skew the results unfavourably for Immigrant IMGs.  However the authors do note that they removed them:

"We excluded visa trainees because they are funded by their home countries to complete their residency training in Canada with the expectation that they will return to practice in the home country (Canadian Post MD Education Registry 2012; Hall et al. 2004)."

Although their description isn't perfect, the definition of a CSA seems correct - basically an IMG who is a Canadian (or PR) before medical school (as opposed to immigrant IMGs who don't fall into that category).  

"We defined CSAs as IMGs who were born in Canada and/or who are Canadian citizens or permanent residents before entering medical school. Immigrant IMGs were IMGs who were neither born in Canada nor Canadian citizens or permanent residents [presumably before medical school]"

[SpeakWhite]

3 hours ago, Andrew said:

You're taking a tiny portion my line of reasoning out of context. You need to go back and re-read the entire thread

No, I am not taking your reasoning out of context. In my opinion, there is no difference between a CSA and an IMG for the purpose of admission into residency in Canada: they are both IMGs and should be treated as such. You are claiming that CSAs should be treated differently than IMGs who were not born in Canada (i.e. they are not "natural-born"), and I am pointing out that nothing in Canadian law supports your argument.

In my opinion, the residency selection process should absolutely favor CMGs irrespective of their path (whether or not they are "natural-born"; for example, some students will have done university training abroad and come to Canada for medical school and become naturalized, or even only re-do clerkship). The corollary is that CSAs should be treated the same as IMGs, because all applicants in this category are citizens or PRs, and there is no basis for discriminating on the basis of where they were born or did their pre-medical education.

I have of course read the entire thread and I am once again surprised that despite all the complaints of nepotism and/or racism, no one supports the residency selection method that would solve the issue, namely sortition.

[Edict]

6 hours ago, indefatigable said:

Thanks for looking at this more carefully!

Visa trainees could definitely skew the results unfavourably for Immigrant IMGs.  However the authors do note that they removed them:

"We excluded visa trainees because they are funded by their home countries to complete their residency training in Canada with the expectation that they will return to practice in the home country (Canadian Post MD Education Registry 2012; Hall et al. 2004)."

Although their description isn't perfect, the definition of a CSA seems correct - basically an IMG who is a Canadian (or PR) before medical school (as opposed to immigrant IMGs who don't fall into that category).  

"We defined CSAs as IMGs who were born in Canada and/or who are Canadian citizens or permanent residents before entering medical school. Immigrant IMGs were IMGs who were neither born in Canada nor Canadian citizens or permanent residents [presumably before medical school]"

Thank you for highlighting those parts! I happily stand corrected, I missed the part about visa trainees. 

[Butterfly_]

Whether you are CMG, CSA, IMG, it does no one any good to fight each other.  

The system sucks for IMGs and I’m sorry to hear that you are frustrated.

I wish you all the best.

[carms2tee2tee3]

I think moral of story here is that life's not fair, system's not fair, Canada's not fair. System's frustrating from every end for CMG and IMG. We can argue all we want but nothing's going to change. At the end of the day, we all suffer equally in residency so I guess that's the only fair part haha.  

[Sceptical]

52 minutes ago, carms2tee2tee3 said:

I think moral of story here is that life's not fair, system's not fair, Canada's not fair. System's frustrating from every end for CMG and IMG. We can argue all we want but nothing's going to change. At the end of the day, we all suffer equally in residency so I guess that's the only fair part haha.  

Sadly medical school and residency training are very good at stamping out the advocacy spirit in all of us, despite being preached that we should be advocates for others. Yes, we can play all we want in our little sandboxes, but trying to rock the boat too much at higher levels usually does not end well. For example, I was genuinely surprised the MCCQE2 was abolished, although it did take a major pandemic and the work of several residents (myself included) to alert governments of the folly of having in-person exams during the height of the lockdown. Now the residency training pipeline (CMG vs CSA vs IMG) is a much bigger beast to tackle than a single MCC exam, and I doubt anything will change unless staff and residents (especially CMGs) get implicated (which is unlikely) or the "system" simply reaches some sort of endpoint and breaks (more likely, for example, by increasing number of CMGs being trained which will squeeze out available residency spots for CSAs/IMGs, the latter 2 groups will become a lot more vocal and maybe something more will happen instead of only having certain CBC articles critical of the "system" appearing at set times of the year).

[Pathognomonic]

Did anyone receive a Hemepath interview invite from Manitoba? 

[indefatigable]

On 4/17/2023 at 6:39 PM, SpeakWhite said:

That being said, IMGs who want to apply to streams where they can compete with CMGs can do so in Québec, where there were 99 unfilled family medicine positions after the R-1 1st iteration.

Although on paper it may appear that QC is open to IMGs, QC has had a history of acting unfavourably towards IMGs in the past.  There was even a report issued by the QC Human Rights Conditions (although it was non-binding).  Things might have changed - but QC has by far the lowest number of IMGs proportionally out of other provinces.  

Here's a quote from 10-15 years ago:

"However, in this case, the Quebec Human Rights Commission conducted a three-year investigation and concluded this week that international medical graduates are subject to "ethnic-based" discrimination.

The inquiry found that while every doctor who graduated from a Quebec medical facility was offered a residency in 2007, two-thirds of foreign-trained doctors who had passed their medical equivalency exams in the province were rejected. The faculties at Quebec's medical schools do not place foreign-trained doctors in residencies because of "apprehension" about their qualifications, the commission said, which is all the more regrettable because 85 residency positions remained vacant."

https://www.theglobeandmail.com/opinion/editorials/stop-doctor-discrimination-in-quebec/article1314853/

"The Quebec government has promised to spend $2.5 million this year to make sure 65 residency spaces are reserved for foreign-trained doctors, the health ministry said."

https://www.cbc.ca/news/canada/montreal/que-schools-deny-foreign-trained-mds-residencies-1.927485

[SpeakWhite]

4 hours ago, indefatigable said:

Although on paper it may appear that QC is open to IMGs, QC has had a history of acting unfavourably towards IMGs in the past.  There was even a report issued by the QC Human Rights Conditions (although it was non-binding).  Things might have changed - but QC has by far the lowest number of IMGs proportionally out of other provinces.

The articles you linked are ancient history, but I'm perfectly willing to accept that the situation described is still current. I agree that racism and discrimination are a problem. Would you be in agreement with me that sortition to assign residency positions would therefore be a fair and effective solution?

[dooogs]

4 hours ago, SpeakWhite said:

The articles you linked are ancient history, but I'm perfectly willing to accept that the situation described is still current. I agree that racism and discrimination are a problem. Would you be in agreement with me that sortition to assign residency positions would therefore be a fair and effective solution?

As a side note for someone who knows people that have gone through the European system of sortition. The same issues remain. People with connections and money are also able to pay off people to get higher marks etc. Sortition would not change anything. I actually think that our system here where there are several people involved in the process makes is less likely you can buy EVERYONE. I think unfortunately humans will always find a way to cheat the system no matter what the system is 

[Sceptical]

2 hours ago, dooogs said:

As a side note for someone who knows people that have gone through the European system of sortition. The same issues remain. People with connections and money are also able to pay off people to get higher marks etc. Sortition would not change anything. I actually think that our system here where there are several people involved in the process makes is less likely you can buy EVERYONE. I think unfortunately humans will always find a way to cheat the system no matter what the system is 

Sortition in its purest form is probably the most effective equalizer in the context of SES/connections/legacy. In the context of the CARMS match, it is very difficult to "pay off people" in standardized tests, and prolly similarly so for the multiple ITERs submitted for us. The problem with the CARMS match is that there are actually very few people involved in the process at the program level (as opposed to MD admissions), and if you know who these few people are (whether legitimately as a prospective candidate trying to know the program director and others, versus other less legitimate means), this greatly increases the chances of your success. Sadly, I do agree with you that in a hypercompetitive environment, this would favor "cheaters" rising to the top, as is the case for all other similarly competitive (non-medical) jobs out there. It becomes difficult to stand out when only adhering to the rules. 

[SpeakWhite]

2 hours ago, dooogs said:

As a side note for someone who knows people that have gone through the European system of sortition.

There is no system, as far as I am aware, of sortition in Europe for residency positions. Usually it is a contest where those with the highest grades get higher picks (a.k.a. "concours"). Sortition means random assignment, unrelated to grades or any other factor besides graduation from medical school and perhaps applicant category.

[dooogs]

56 minutes ago, SpeakWhite said:

There is no system, as far as I am aware, of sortition in Europe for residency positions. Usually it is a contest where those with the highest grades get higher picks (a.k.a. "concours"). Sortition means random assignment, unrelated to grades or any other factor besides graduation from medical school and perhaps applicant category.

Ops yes I confused the two! I thought you meant by exam only 

[indefatigable]

20 hours ago, SpeakWhite said:

The articles you linked are ancient history, but I'm perfectly willing to accept that the situation described is still current. I agree that racism and discrimination are a problem.

It looks like Québec did create an organization CÉDIS after the human rights commission in 2010.  12 years after this it seems there's been some improvement, with more IMGs able to work in QC, but still room to grow.  QC still has the lowest proportion of IMGs (9%) well bellow Nunavut (16%) or PEI (18%) and obviously still has many unfilled residency positions despite IMGs who have successfully done clinical rotations with credentials recognized - here's an update from last year.

https://ici.radio-canada.ca/nouvelle/1928068/medecins-etrangers-discrimination-quebec-saskatchewan

Edit: Of course you are free to choose your own user name, but the poem that your name is referring is from a  Palaeolithic era compared to the news articles.  As you know, QC has passed an aggressive French-language Bill which suspends constitutional rights of other language speakers to achieves its ends.

20 hours ago, SpeakWhite said:

Would you be in agreement with me that sortition to assign residency positions would therefore be a fair and effective solution?

Sortition potentially has advantages including less gunning, less nepotism/connections, less stress,.. and much less system overhead.  

Still applicant performance and motivation could take a drop since these are irrelevant under a pure sortition scheme.  So I'm not sure how much program buy-in there would be - at the minimum programs probably want applicants who have shown some interest e.g. rotation and some ability.      

So then should sortition be restricted to applicants who have done a rotation in a discipline?  But does it matter if someone has done two weeks vs eight or more weeks?  Potentially an applicant could increase their chances of matching by spreading out their electives as much as possible.  

So it gets complicated pretty quickly, but maybe it's possible to come up with something which improves on the current system with some limited sortition.  Perhaps programs posting up criteria which allow anyone to enter the draw run through CaRMS haha?

The other caveat is there would clearly be an advantage to apply to as many programs as possible under pure sortition, which would still favour those with more resources.

[Andrew]

On 4/17/2023 at 8:14 PM, SpeakWhite said:

No, I am not taking your reasoning out of context. In my opinion, there is no difference between a CSA and an IMG for the purpose of admission into residency in Canada: they are both IMGs and should be treated as such. You are claiming that CSAs should be treated differently than IMGs who were not born in Canada (i.e. they are not "natural-born"), and I am pointing out that nothing in Canadian law supports your argument.

In my opinion, the residency selection process should absolutely favor CMGs irrespective of their path (whether or not they are "natural-born"; for example, some students will have done university training abroad and come to Canada for medical school and become naturalized, or even only re-do clerkship). The corollary is that CSAs should be treated the same as IMGs, because all applicants in this category are citizens or PRs, and there is no basis for discriminating on the basis of where they were born or did their pre-medical education.

I have of course read the entire thread and I am once again surprised that despite all the complaints of nepotism and/or racism, no one supports the residency selection method that would solve the issue, namely sortition.

I think you are fixating on my use of the US President and Natural Born Citizen. I used this example only to illustrate a point: that the most powerful country in the world, the country which most other countries aspire to be, the beacon of freedom and progress, has this clause.

As for why CSAs should be given priority, I already outlined that. They have deeper community roots, were likely born/raised/educated in Canada, understand Canadian culture and institutions. "Most" CSAs have done their training in a Commonwealth country such as Australia or Ireland with very similar culture/training standards/institutions to Canada. (for the purpose of this line of reasoning, it doesn't matter whether a CSA was born in Canada or immigrated here at a young age, say age 5. I'm not going to split hairs with you but there is obviously a huge difference in the above elements for a immigrant who has lived in Canada since age 5 [I would basically consider this a CSA] and an immigrant who is just arriving in Canada for the first time at age 40, this is an IMG).

CSAs more readily integrate into the Canadian medical system. There is a wealth of data that supports that CMGs have higher CCFP exam pass rates than IMGs and also that they perform better in a variety of real-world clinical evaluations (the most notable ones the IMGs lack are cultural-specific ones, such as women's rights, sexual issues, mental health issues among others). I don't know whether there is comparable data for CSAs, but I would guess they also perform better on these issues.

 

Most corporations would prefer to hire employees that are already familiar with their workplace culture or systems. It is far easier to integrate these employees. You keep issuing the statement that "nothing in Canadian law supports this". Canadian law allows hiring practices based on non-discriminatory criteria. Hiring based on ease of integration is valid.

[SpeakWhite]

1 hour ago, indefatigable said:

Sortition potentially has advantages including less gunning, less nepotism/connections, less stress,.. and much less system overhead.  

Still applicant performance and motivation could take a drop since these are irrelevant under a pure sortition scheme.

The motivation for students would be to receive broad exposure in many areas of medicine, since they would be aware of the large range of possible practice outcomes.

Quote

 So I'm not sure how much program buy-in there would be - at the minimum programs probably want applicants who have shown some interest e.g. rotation and some ability.

Programs don't need to buy in if they simply have no say in which residents get selected.

Quote

So then should sortition be restricted to applicants who have done a rotation in a discipline?  But does it matter if someone has done two weeks vs eight or more weeks?  Potentially an applicant could increase their chances of matching by spreading out their electives as much as possible. 

I'm not suggesting this at all - number of electives shouldn't be relevant beause getting electives in the first place is a random, unfair process where students can mobilize insider access.

Quote

The other caveat is there would clearly be an advantage to apply to as many programs as possible under pure sortition, which would still favour those with more resources.

If the system is pure sortition, then there is no justification to charge more for each program application. Perhaps the charge could be by province (due to assessment of eligibility for licensure). It would be much more fair than the current system which is becoming more and more expensive.

 

44 minutes ago, Andrew said:

[QUOTE]

I understand your point, which you just restated, and my disagreement remains the same. Medical student numbers are increasing across the country. Would you be in favor of simply removing the entry route for all IMGs, including CSAs, and only training CMGs?

[indefatigable]

9 minutes ago, SpeakWhite said:

The motivation for students would be to receive broad exposure in many areas of medicine, since they would be aware of the large range of possible practice outcomes.

Programs don't need to buy in if they simply have no say in which residents get selected.

I'm not suggesting this at all - number of electives shouldn't be relevant beause getting electives in the first place is a random, unfair process where students can mobilize insider access.

If the system is pure sortition, then there is no justification to charge more for each program application. Perhaps the charge could be by province (due to assessment of eligibility for licensure). It would be much more fair than the current system which is becoming more and more expensive.

Perhaps you could explain your sortition approach?  Is there any role of student interest in discipline?  After all, at the moment there's around 80% of students matching to first choice discipline so I think any change would have to improve on that.  

I do think there are potential motivation issues with a pure sortition approach.  If there's no incentive or consequence for putting in good/bad performance in terms of matching, I can see students getting more cynical especially if they may end up in a discipline they don't want to do whether it be surgery, psychiatry or pathology.  Likewise, matching unhappy students to disciplines they don't want to do might also make programs unhappy and create more problems in the future with students trying to transfer,..

[Sceptical]

10 minutes ago, indefatigable said:

Perhaps you could explain your sortition approach?  Is there any role of student interest in discipline?  After all, at the moment there's around 80% of students matching to first choice discipline so I think any change would have to improve on that.  

I do think there are potential motivation issues with a pure sortition approach.  If there's no incentive or consequence for putting in good/bad performance in terms of matching, I can see students getting more cynical especially if they may end up in a discipline they don't want to do whether it be surgery, psychiatry or pathology.  Likewise, matching unhappy students to disciplines they don't want to do might also make programs unhappy and create more problems in the future with students trying to transfer,..

I think @SpeakWhite's sortition idea came from this thread, which I was also following: 
 

Edit: added link for the specific post

[SpeakWhite]

4 minutes ago, indefatigable said:

Perhaps you could explain your sortition approach?  Is there any role of student interest in discipline?  After all, at the moment there's around 80% of students matching to first choice discipline so I think any change would have to improve on that. 

1. All applicants (or all CMGs, at first) submit rank-order lists of programs where they are willing to train.

2. CaRMS randomly selects applicants one at a time and and assigns them the highest-ranked program on their list where a position is still available.

3. Optional: assign unmatched CMGs to unfilled positions randomly.

4. Optional: repeat steps 1-3 for all applicants including IMGs.

[Andrew]

1 hour ago, SpeakWhite said:

I understand your point, which you just restated, and my disagreement remains the same. Medical student numbers are increasing across the country. Would you be in favor of simply removing the entry route for all IMGs, including CSAs, and only training CMGs?

Residency spot capacity for CMGs is very slightly more than 1:1 (meaning there is very slightly more than 1 spot per CMG). So this, in addition to existing CSA/IMG spots means we do have additional spots for either CSAs or IMGs, so it makes sense to utilize it somehow. So no, removing the entry route would make no sense CURRENTLY.

The overall solution to the "problem" (assuming we even agree there is one, there is a question of if we need more doctors overall, and a question of whether we need to train IMGs in residency spots), is to increase Canadian medical school spots, and correspondingly increase residency spots for CMGs. Until then, we have the current system where CSAs are given priority to leftover spots or non-CMG allocated spots and IMGs after that. 

It's relatively "easy" to create new medical school spots. In BC SFU is proposing to create a new medical school. It's much harder to create Residency spots to accommodate new medical students. Using that chain of logic, there is no shortage of CMGs to fill Residency spots, so I question whether we even need to use Residency spots to train IMGs. Imagine if SFU medical school is created, 100-200 new CMGs instantly, now you need to find Residency spots for them, either by creating new spots or taking existing IMG-only spots and converting to them to CMG spots.

So, IN THE FUTURE, in my opinion, assuming we increased medical school spots, it makes no sense to train IMGs, just increase the supply of Canadian medical students and place all of them. So yes, I would be in favor of removing IMG entry in that scenario.

[Imghope]

You know it’s funny all this fighting and trying to favour one stream to another, as Canadian citizens the best way for those at disadvantage (aka IMGs) to circumvent the system, especially with new CPSO rules is to do residency in the US (any school) and fly right back and you can practice like any other Canadian residency graduate and you get paid more during residency as well. The number of programs is not comparable to Canada. 
the issue is, people who go down south to train rarely come back to Canada to practice. 

[penicillin]

29 minutes ago, Imghope said:

You know it’s funny all this fighting and trying to favour one stream to another, as Canadian citizens the best way for those at disadvantage (aka IMGs) to circumvent the system, especially with new CPSO rules is to do residency in the US (any school) and fly right back and you can practice like any other Canadian residency graduate and you get paid more during residency as well. The number of programs is not comparable to Canada. 
the issue is, people who go down south to train rarely come back to Canada to practice. 

What do you mean by the new CPSO rules? 

[indefatigable]

2 hours ago, Sceptical said:

I think @SpeakWhite's sortition idea came from this thread, which I was also following: 

I did see that post and like most other people did take it as a bit of a joke.

2 hours ago, SpeakWhite said:

1. All applicants (or all CMGs, at first) submit rank-order lists of programs where they are willing to train.

2. CaRMS randomly selects applicants one at a time and and assigns them the highest-ranked program on their list where a position is still available.

3. Optional: assign unmatched CMGs to unfilled positions randomly.

4. Optional: repeat steps 1-3 for all applicants including IMGs.

It's an interesting idea, but unfortunately I don't believe it would work any better.  To summarize, from what I understand, your proposal basically removes any program rank lists and substitutes a random list in place. 

Firstly, unfortunately, CaRMS does charge to use its platform.  Even if programs aren't submitting rank lists, applying to a program does cost money.  So, once again, applicants with more money can buy more tickets to the lottery and have a better chance of matching to programs that they prefer.

Secondly, while there are certainly problems with nepotism etc under the current system, your proposal removes any pretence of applicants and programs being best matched to each other.   Lotteries can create winners but they create a lot of losers too.  

1 hour ago, Imghope said:

You know it’s funny all this fighting and trying to favour one stream to another, as Canadian citizens the best way for those at disadvantage (aka IMGs) to circumvent the system, especially with new CPSO rules is to do residency in the US (any school) and fly right back and you can practice like any other Canadian residency graduate and you get paid more during residency as well. The number of programs is not comparable to Canada. 
the issue is, people who go down south to train rarely come back to Canada to practice. 

I don't see that as in issue - if IMGs train and then choose to stay the US then that's their choice.   At least under the rule change, Canadians citizens or PRs that choose to work and stay in the US will not be able to protest that they are unable to come back to Canada because of licensing restrictions.