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CMAJ news article on Canadians studying medicine abroad

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CMAJ • April 10, 2007; 176 (8). doi:10.1503/cmaj.070328.



Estimated 1500 Canadians studying medicine abroad

Patrick Sullivan


Richmond, Ont.


The number of Canadians studying medicine outside Canada is almost 4 times higher than previously estimated, a new survey indicates. The first of its type, the survey was completed for Health Canada last October by Canadian Resident Matching Service (CARMS) Executive Director Sandra Banner. After surveying offshore medical schools that accept Canadian students, she estimated that up to 1500 Canadians are studying medicine outside Canada and the US. Previous estimates pegged the number at 400.


Of the 13 offshore medical schools contacted, 7 completed a survey. All 13 schools distributed a separate survey to their Canadian undergraduates; 525 completed it.


The estimate of 1500 Canadian students comes from known Canadian offshore enrolment and information gathered during the study.


Peter Nealon agrees with Banner's estimate. The director of the California-based Atlantic Bridge Program that recruits North American students for medical and veterinary schools in Ireland says more than 300 Canadians are now studying at 4 Irish medical schools, and 60 to 70 new ones join them annually.


Although entry-level positions in Canada have increased, it's obviously not sufficient. Canada has 7.1 first-year medical school openings per 100 000 people, compared with 12.9 per 100 000 in the UK. The Association of Faculties of Medicine in Canada (AFMC), reports that 8700 students were enrolled in undergraduate studies at 17 medical schools in 2005-06. More than 2400 entry-level positions are available annually, an increase of more than 600 positions (34%) since 2000. However, there has also been a 20% increase in the number of applications for these openings during the same period. The bottom-line, according to AFMC, is that only 25% of applicants were admitted to Canadian schools in 2005–06.


"Many outstanding candidates are turned down by the Canadian schools," says Nealon.


Schulich School of Medicine & Dentistry at the University of Western Ontario received 2400 applications for its 147 openings in 2007, meaning applicants have a roughly 6% chance of admittance.


"Every year I am saddened by our inability to train more of these outstanding young Canadians," says Dean Carol Herbert. "The only consolation is that many of them are persistent and get into another Canadian school, and some of them, who can afford it, go abroad for their education."


The CARMS study confirms that demand for medical training in Canada far outstrips supply. Banner surveyed 525 Canadian students studying at 13 offshore schools: 4 in the Caribbean, 4 in Ireland, 3 in Australia, 1 in Poland and 1 in England. (The figures do not include schools in several countries, such as Hungary, where Canadians are also known to study.) The survey revealed that 222 Canadians are studying at 3 Australian universities; 61 are studying in Poland; 40 are at Trinity College in Dublin; 229 are at St. George's University in Grenada; and 26 are studying in the Netherlands Antilles.


When asked why they studied abroad, 46% of respondants (whose reasons could be determined) said they left Canada because they weren't accepted by a Canadian school. Another 27% cited similar reasons including the feeling that they were unlikely to be accepted by a Canadian school, the limited number of positions and tight competition in Canada, and less onerous admission requirements at the foreign schools.


The survey also revealed that gender differences among the Canadian expatriates is a reversal of Canadian demographics. "The proportion of [Canadian] males studying abroad is 55%, while in Canadian medical schools for 2005–06 it was 41%," says Banner.


Banner found that two-thirds (67%) of the Canadians studying abroad intend to seek postgraduate training at home, including almost three-quarters of those who will graduate in 2010.


So might these "offshore Canadians" be a partial solution to Canada's ongoing MD shortages? Banner suggests there is a need to review Canada's "clinical educational capacity." If insufficient training capacity is available for the expatriates, she says, "there is a significant potential loss of physician resources for Canada. If repatriation is the goal, ways that opportunities can be provided to pursue undergraduate clerkships and postgraduate training in Canada in a broad range of disciplines must be studied."


However, she has a caveat: a call for an in-depth study of the offshore medical schools that are attracting Canadian students, "particularly in the Caribbean, where the number of [for-profit] medical schools has quadrupled in the last decade." The study would include an assessment of curriculum quality, accreditation status, quality of clinical clerkships and the ease or ability to seek postgraduate training in the US.


The survey found that only 9% of Canadian students studying in the Caribbean had been able to schedule clinical elective rotations in Canada, compared with 41% of students studying in Western Europe.


Concern about the quality of some offshore training is emerging in the US. Last year, the American Medical News reported that "a recent explosion in the number of for-profit Caribbean medical schools catering to US students" had forced the Federation of State Medical Boards to review systems used to evaluate graduates of these schools.


A 2006 report from the federation found that while more than 90% of graduates of American and Canadian medical schools pass step 1 of the US Medical Licensing Examination on their first try, only 53% of American students who studied at an overseas school do the same. Dale Austin, the federation's senior vice-president, told the American Medical News that state licensing boards "are increasingly concerned about international medical graduates from these schools, their calibre and the rigour of their basic medical education."


Those concerns don't extend to graduates of well-established, accredited schools in countries such as Ireland and Australia. Nealon says Canadian graduates of the Irish schools "routinely secure some of the most prestigious residency training positions in North America." He acknowledges that the training, which lasts from 4 to 6 years, is expensive: tuition and living expenses will cost $60 000 to $80 000 annually.


Dr. Ilana Porzecanski, a BC native who graduated from University College Dublin in 2002, says it is now easier for graduates of the Irish schools to return to Canada for residency training, but only in certain specialties, such as family medicine and psychiatry.


Those hoping to enter high-demand specialties that offer few openings — ophthalmology and dermatology are examples — have a much harder time because of the competition from in-country graduates. In the 2007 match, for instance, only one international medical graduate applied for training in each of those specialties, while 85 applied for family medicine slots.


Porzecanski, who completes her training in critical care medicine in New York City this spring, will not be returning to Canada — she has accepted a post at a hospital in Medford, Oregon.


Ireland-trained Canadians go to the Rock


The impact of international medical graduates on Canadian medicine is well known, since they account for about 25% of the physician workforce. Now Newfoundland appears to be setting its recruiting sights on another type of international graduate: Canadian graduates of Irish medical schools.


In 2003 those sights fell on Dr. Rob O'Connor, a native of Morpeth, a tiny town in Southwestern Ontario. After graduating from University College Dublin (UCD) in 2003, he became 1 of 5 Canadian trainees from Ireland selected that year for the family medicine program at Memorial University of Newfoundland. In fact, the "Canadian Irish" accounted for one-quarter of the residents in Memorial's family medicine program in 2003.


"I entered the Canadian match, I ranked the Canadian programs, I got my first choice," says O'Connor, who now practises at the hospital in Twillingate, Nfld., covering emergency department shifts, providing inpatient service and working at a family medicine clinic.


Although acceptance into an American residency program would have been a formality — "they basically said, 'here's the form, sign it' " — O'Connor wanted to return to Canada. "I am more comfortable with the values in Canada," he says.


O'Connor isn't alone. Dr. Sujay Patel, a UK native who grew up in Newfoundland before graduating from UCD, "stepped off a plane" in 2003 and straight into a psychiatry residency at Memorial, where he is now chief psychiatric resident. Patel says he has no regrets about his decision to pursue offshore training, which he credits with allowing him to "excel" since returning to home. "Canadians who trained outside Canada are hard workers and truly cherish being afforded the opportunity to achieve a residency in Canada, even if they may have been disappointed at being turned down for medical training here."


O'Connor does advise anyone considering the offshore route to medical practice to tally the financial burden and to visit the offshore school and speak to alumni before making a commitment.


Patel thinks the answer to Canada's HR problems is to offer more opportunity for people to train in Canada. "If that isn't feasible, then yes, Canada should do everything it can to assist offshore Canadian graduates to complete their training outside the country and then to return here for residency, with obstacles no different from those facing the in-Canada medical graduate."

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