Canadian versus American residency opportunities for Canadian med students

[treadmill]

Hi,

I am just entering Canadian medical school and have begun to think of specialties. I know that certain residencies are pretty rare. I've heard that some of them may be up to say 10 spots and so on.

 

I was just wondering how the U.S compared to Canada in terms of residency availabilities. For instance, I heard that there are many more dermatology programs (40ish) than in Canada.

 

So is it a good idea to consider writing the USMLE after Canadian medical school if you want to get into the extremely competitive specialties? (As you may have a better chance applying to the U.S than Canada)

 

And then is it possible to return back to Canada after making it in the U.S? Even if it takes a few years extra to get back, it might still be better than not making it at all in Canada, right?

 

Thanks!

[BlackJack]

I have limited experience and knowledge when it comes to doing residencies in the USA, but here is some info:

 

1. There are more residency spots for competitive programs like derm in the USA( 6 vs 40ish). Unfortunately, there are also more medical students - approximately 10x more than in Canada. For some specialties like Emergency, there are far more residency spots in the USA than in Canada: something like 22 to >100. Additionally, to do a competitive residency in the USA requires that you DESTROY the USMLE step I to be even considered. If you screw that exam up, then that's it, you're done. Although, in Canada, I'm not even sure what landing a residency requires; its all pretty arbitrary - I've seen superstars go unmatched, and questionable admissions land hardcore spots. C'est la vie.

 

That being said, there are far more networking opportunities in the USA solely because there are more doctors and more medical schools. There are far more research opportunities as well.

 

I also remember a post by Moo stating that residency training in the USA is far more "hardcore" than in Canada. I'm not sure of the specifics, but you could search the forums for it.

 

2. Not all residency spots are equal in the USA. In Canada, everything is essentially standardized. Yes, some programs are better than others, but not drastically so. Residency spots in the USA, however, can vary widely in training quality.

 

3. Some Canadian residencies are not recognized by the USA, such as CCFP(EM) and Neurosurgery. So if you want to go to the US to practice in the future, keep in mind some Canadian residencies won't cut it for that purpose.

 

4. I'm not certain about American residencies not being recognized by Canada. As far as I know, they all are. However, the Canadian licensing exam focuses heavily on physical diagnosis, whereas residencies in the US train you more for investigatory medicine(is that even a term?). Thus, some top-tier USA residents actually fail the Canadian licensing exams on their first go, because they just weren't trained in the heavy physical diagnosis element that's required to pass.

 

 

If you want my two-cents, I think it would be a good idea to write the USMLE step I, but only if you are certain you will maim it: >240. Remember, if you're trying to land a competitive spot AND you're not from the USA, you have the deck stacked against you and thus must stand out.

[treadmill]

Thanks for the advice, Blackjack. It really helps. After taking ratios into consideration, American residencies sound as competitive as those in Canada. And I'll definitely have to take the USMLE seriously. Thanks again!

[Madz25]

There are also visa issues which people don't consider. The "good" visa is the H1B but it is very difficult to get. I believe you need to have completed USMLE step 3 in order to be eligible - but you usually don't write that exam until you're already IN residency. The other option is the J-1 visa, which is relatively easier to get but has a lot more restrictions associated with - one of which is that you must return to your country of residence for at least 2 years after you've completed your training.

 

Just something to keep in mind if you're considering the US.

[Ian Wong]

I did med school at UBC, and am currently doing my radiology residency in the US. I am in my PGY-5 year, which is my last year in residency.

 

It is possible to do residency in the US, but not easily. In my UBC class, only one other person went to the US for residency. She did anesthesiology, and went to the US primarily because her fiance was American.

 

One major hurdle is the visa issue. If you don't have US citizenship or a green card, you will need a visa to do residency in the US. For numerous reasons, most US program directors want nothing to do with visas. It's an additional headache for them. It's more paperwork, and if that person ever loses their visa during residency, they will be unable to enter/stay in the US, which is obviously a nightmare for a program director.

 

There are two potential types of visas.

 

1) H1B visa. This is the harder visa to get from US immigration. It allows you to stay in the US after your training, and puts you on the path to getting a green card, which can eventually lead to the option of getting US citizenship. Unfortunately, this visa costs the program money to obtain. Additionally, you cannot apply for this visa unless you have taken and passed USMLE Step 3. You cannot for Step 3 until after you graduate medical school. You then need to take and pass this exam, and get the results before you can start applying for the H1B visa. That means that it's nearly impossible to graduate from medical school and start internship/residency on time on July 1.

 

Most competitive specialties will not offer an H1B visa, because they have more than enough applications from qualified US applicants, and the few foreign applicants that they get would be more than happy to settle for a J-1 visa.

 

Non-competitive specialties in the US like Family Medicine, Pediatrics, Psych, Internal Medicine etc, often offer H1B visas to their foreign applicants as an incentive in order to fill their programs and avoid going unfilled.

 

2) J-1 visa. This is the more likely visa that you will end up with if you are applying to a competitive specialty, such as Derm, Plastics, Ophtho, ENT, Urology, Radiology, etc. This visa is easier to obtain from your residency program. A catch is that you need Health Canada to issue you a "Statement of Need", which is a letter stating that Canada needs more physicians in your specialty. If you can't get this letter, you can't get a J-1 visa.

 

I didn't have any problems getting this letter, but I've heard that that can be an issue sometimes, depending on what province you are coming from. For example, let's say you are from Manitoba, and want a "Statement of Need" letter to do Orthopedic Surgery in the US. If Manitoba gives you that letter, there's no guarantee that you will come back to Manitoba to practise. On the other hand, if they refuse you that letter, and you don't match into Ortho in CaRMS, chances are good that you'll pick up an unfilled Manitoba residency spot in Family Medicine or something in the second round.

 

I should note that while I've heard anecdotally of this sort of thing happening, I didn't experience it myself, and therefore can't verify its prevalence.

 

The other issue with the J-1 visa is that you need to come back to Canada for 2 years once your training is complete. If you don't want to do that, you can apply for a J-1 waiver in the US, which means that you will work in a VA (Veteran's Administration) hospital in the US for 3 years, or an underserved area of the US for 3 years. Both of these options can be distasteful for a number of reasons.

 

 

In order to match in the US in a competitive specialty, you need to dominate the USMLE Step 1, which is the single most important factor in getting the interview invites you need in order to match successfully. This exam is usually done in the summer after your Med 2 year. It is heavily weighted in the basic sciences. An average score on Step 1 (such as a 220), combined with your Canadian background, is probably enough to sink your application to a competitive specialty in the US.

 

US schools also care extensively about your clinical grades, and your letters of recommendations. Still, since most every residency program uses USMLE Step 1 scores with cutoffs, if you don't make the numerical cut-off, you will instantly be rejected, no matter what your medical school grades are.

 

Also, unfortunately, most US programs know very little about Canadian programs (they all seem to think McGill is the best school in Canada, some have heard of UBC and U of T, and pretty much all the other Canadian schools are entirely unknown to them). This makes it tough to establish any amount of "street credibility", because medical school reputation definitely counts in getting interviews for residency.

 

An applicant coming from a "name school" in the US (like UCSF, Harvard, or Hopkins) is going to get many more interview invites compared to an applicant with identical grades coming out of a no name US med school. Coming out of a Canadian med school is even worse, unless it happens to be McGill.

 

 

Another hurdle is that many US residencies are shorter than their Canadian equivalents, and therefore the Royal College will make you do additional training before they allow you to sit for the Canadian exam.

 

For example, OB/GYN, Ophtho, Psych, PM&R, Path, Derm, and Anesthesiology are all 4 year residencies in the US. They are all 5 year residencies in Canada.

 

Most Emergency Medicine residencies in the US are 3 years, with some being 4 years. The complete Royal College Emergency Medicine residency in Canada is 5 years, although you can get something similar by doing 2 years of Family Medicine in Canada followed by a 1 year CCFP-EM fellowship year.

 

You are able to practise as an internist or pediatrician after 3 years of residency in the US. In Canada, general IM or general peds takes 4 years of residency. In an unusual twist, while Family Medicine is only 2 years in Canada, it's a 3 year residency in the US.

 

I am lucky in that radiology is 5 years in both Canada and the US, and as a result, doing a US residency should still allow me to write the Canadian Royal College exam. General Surgery and the surgical subspecialties (Plastics, ENT, Ortho, Urology, Neurosurg) are all essentially equivalent in length in their clinical years, although many residencies have a research component to them.

 

Thus far in my training I have taken all the Canadian and US exams at their appropriate times (MCCQE Parts 1 and 2, USMLE Steps 1, 2, and 3), and therefore after taking and passing both the Canadian and US radiology boards, I should be licensed to practise in either country. Of course, I have to pass those exams first, which is starting to cause me some serious anxiety since I've just started my PGY-5 year...

 

Ian

[Satsuma]

Along similar lines....does Ian or anyone else know how you would go about completing a fellowship in the US?

 

Do you have to have the American exams completed or can you simply go with your Canadian exams?

 

And if you wanted to do a 1-year fellowship in the US during the 4th year "elective in year" in emerg would you be able to do that?

 

Thanks

[treadmill]

Thanks for the replies everyone. Ian, that was one of the most awesome posts ever. I'm just a little confused...

 

I thought that USMLE step 3 was written at the end of first year of residency?

 

So doesn't that mean that you can NEVER get an H1B visa before entering competitive residencies? (As you wont write the USMLE 3 until you spend a year in the residency) I'm guessing you would need a J-1 visa when entering and that after you enter and write USMLE 3 you'd apply for the H1B visa.

 

I'd really appreciate some clarification. Thanks again for your awesome post, Ian! It really helped.

[Ian Wong]

I do not know the answers regarding Canadian residency graduates getting US fellowships. For me, since I'm doing a US residency, I'm automatically eligible to do a US fellowship assuming I pass my US boards. It does seem like it would be possible for me to do a US fellowship even if I failed my US boards, but presumably that might affect certain things like being able to sign off reports without attending supervision, or perhaps billing/malpractice stuff.

 

Most US med school graduates take USMLE Step 3 sometime near the end of their PGY-1 year. What isn't common knowledge to most US folks, is that many of the US states allow you to take Step 3 without any post-graduate training. If you register to take Step 3 through a state that doesn't have any requirements, then you are good to go.

 

Here's the website listing all of the states and their Step 3 requirements. Note that many states, including Arkansas, California, Connecticut, Delaware, Maryland, Nevada, Oklahoma, Rhode Island, South Carolina, South Dakota, Texas, Utah, Virginia, and West Virginia all have absolutely no post-graduate requirements prior to registering for Step 3.

 

http://www.fsmb.org/usmle_requirementschart.html?

 

For example, after I graduated med school in 2003, after going unmatched in ENT, I decided that I would make myself the best possible applicant for 2004.

 

I took Steps 1 and 2, and used those scores to apply for US residency positions in the NRMP 2004 match. Right after finishing all of those interviews, and well before Match Day, I registered for Step 3 through California (which doesn't have a post-graduate requirement). I then went down to Portland, Oregon, where my sister lives, and took it at a Portland Prometric facility.

 

You can register for Step 3 using any state you want, and then take the exam in any state you want. It's pretty confusing. The long and the short of it is that immediately after you graduate med school, you could apply for Step 3 right away through one of the above states, and take it before you start internship/residency. If the scores came back in time, and your program was willing to get you an H1B, and if all of the paperwork could be done in time for the H1B to be available by July 1, then it's possible to use it for residency without taking a year off.

 

Unfortunately, the timeline typically breaks down, and so things don't work out so well. In a way, it's sort of moot, because if you are going after a competitive US specialty, those specialties tend not to sponsor H1B visas. If you are going after a non-competitive US specialty, then chances are good that you could have gotten that specialty in Canada anyway.

 

I will admit that the J-1 visa is a frustrating thing. The home residency requirement can be a real pain, particularly if you put down a lot of roots in the location where you are training, and don't want to leave it to come back to Canada for two years. Even marrying a US citizen and having a kid won't get you out of the home residency clause.

 

Additionally, you cannot do any moonlighting while on a J-1 visa, while moonlighting is entirely legit on an H1B visa. Compared to my classmates who are almost all uniformly moonlighting reading films and doing other radiology stuff, I'm down several tens of thousands of dollars in income compared to them. That's a lot of money and valuable additional clinical experience to leave on the table.

 

The J-1 visa also has to be renewed annually, which actually hasn't been too unpleasant. It requires you to fill out a couple of forms, get your program director and GME office to sign off on it, and then send the whole package along with $200 to the ECFMG organization in Philadelphia, who then do the rest of the legwork to get you renewed.

 

Ian

[KFed]

This thread is great! Please.... just keep talking

 

Thank you.

[Madz25]

To add to what Ian said in terms of getting out of the J-1 home residency requirement - I've heard that if you agree to work in a rural area for X amount of years, you can get out of that requirement and get an H1B. I personally don't know anyone that has done that but if you're interested in the US and can only get a J-1 then its definitely something you should look into.

[Ian Wong]

If you don't want to do that, you can apply for a J-1 waiver in the US, which means that you will work in a VA (Veteran's Administration) hospital in the US for 3 years, or an underserved area of the US for 3 years.

To get out of the J-1 home requirement takes 3 years at an underserved area, or at a VA hospital.

 

Part of the problem with taking these spots is that the people who you are working with, who are the individuals/hospitals that hire you on for this job know that you are on a waiver pathway. That means that if you don't complete the 3 years, you don't get your waiver. It also means that they can either pay you way below the market rate, or else abuse you with call and work responsibilities that other physicians wouldn't tolerate.

 

For that reason, it's really buyer-beware if you try to do one of these waivers. You could find yourself in a situation where you are getting totally exploited, without any recourse whatsoever. If you are dismissed or resign from this position, the J-1 home requirement kicks back in, and you need to leave the US.

 

The other thing is that it's not a given that you are going to get one of these underserved waivers. Some of these programs that offer these waivers (Google "Conrad 30" for an example), are looking for specific types of physicians, often those in primary care. If you are getting a J-1 visa, chances are good that it is for a competitive specialty (ie. not a primary care specialty). It's possible that you may not get priority for those limited numbers of waiver spots (which are not unlimited), because those spots may preferentially go to primary care docs.

 

Ian

[Ian Wong]

Great thread, but is it possible to practice in the US through doing med school in Canada, residency in Canada, fellowship in the US and board exams in the US?

Yes, with the caveat that some US boards don't recognize Canadian training (it is specialty-specific). Additionally, some US states recognize the MCCQE Canadian exams as equivalent to the USMLE exams. If you wanted to toe the line completely, you would take all of the USMLE exams at their appropriate times, and also take the US specialty board exam (assuming that your Canadian residency qualifies you to take it).

 

Ian

[treadmill]

Thanks again for all the awesome replies Ian. I now feel like an expert on U.S visas

[relf]

Ian, you are a wealth of knowledge.

 

Will a canadian who is trained in the US have an easier time obtaining a H1B visa for residency purposes, compared to a Canadian trained in Canada?

 

(If i had to guess, it would be far easier for a canadian trained in the US to obtain a H1B visa through their home school/hospital, but far harder to obtain a H1B through a residency program in a completely different region of the USA....e.g. a canadian at NYU will know the NYU program directors who might be willing to help out with the H1B application, but if that same student were to apply to UCLA, they wouldnt help as much)

 

this is all very interesting, because i will be an M1 in the US in august!

[Ian Wong]

I don't know the answer to your question, as I don't personally know any Canadians who have gone to the US for med school, and then stayed there on an H1B in a competitive specialty.

 

As I mentioned before, programs in general are fairly disinterested in sponsoring the H1B visa, because of the paperwork required. Once you get far along enough into med school, and hopefully have a feel of what sort of specialties and your preferred locations for residency would be, it would be a good idea to start visiting their websites to see if they sponsor H1B visas versus J-1 visas.

 

Even better would be to contact them individually, because what is currently on the website is not necessarily what their current policy is.

 

On that note, I've gotten a couple additional questions via PM regarding J-1 visa Statements of Need.

 

Here is a very important website, the Health Canada website, with all of the criteria and paperwork you need to complete in order to get a Statement of Need which legitimizes your J-1 visa application. Definitely a website you want to get familiar with if you are considering doing a US residency, particularly in a competitive specialty where you might only be offered a J-1 visa.

 

http://www.hc-sc.gc.ca/hcs-sss/hhr-rhs/strateg/postgrad-postdoc/index-eng.php

 

Ian

[lostintime]

Awesome posts, very informative!

 

So there's a lot of downsides to going to the US for residency/future careers (visa nightmares, etc.), but what do you think are the biggest advantages?

 

Of course I understand if your finace is American etc., but for people who don't have a strong "I can only practice in Canada" attitude, what are some of the pros?

 

-possibly more residency spots? (but isn't there more competition for the competitive ones anyway?)

-better pay as a resident?

-better pay in the future?

-lower taxes?

-love for America? (haha)

 

Thanks!

[relf]

i would hafta say better weather (west coast, south), better pay after residency, wanting to stay where you went to medical school, wanting to be closer to your hometown (e.g. if you're from TO, maybe you'd rather be living in Buffalo than BC/NFLD)...

[Ian Wong]

Possible advantages: potentially slightly more money during residency, potentially significantly more money as an attending, much greater access to technology and expensive procedures/OR time, additional chances to land a residency in your chosen field, exposure to an entirely different sort of health-care system (just as easily a potential negative, but I feel I've learned a lot having a chance to cross-train in the US).

 

Possible disadvantages: potentially not being able to be licensed in Canada without additional hassles, visa issues, possible stigma of having gone to the US for residency (not sure about this yet, but it's theoretically possible at least), wider variation in quality of residency programs (while Canada's programs are all generally very good, there's a much wider spectrum of program quality in the US).

 

All in all, for the appropriate person, getting a US residency could be a wonderful thing. It really is a multi-factorial process that doesn't have a single straightforward answer.

 

Ian

[skvangs]

Hey...sorry to bump an old thread, but does anyone know which states recognize the MCCQE exams as an equivalent to the USMLE?

[Lactic Folly]

Hey...sorry to bump an old thread, but does anyone know which states recognize the MCCQE exams as an equivalent to the USMLE?

 

I don't have the answer to that, but just wanted to add a caveat that policies may change anytime.. something I took into consideration when deciding to write the USMLE.