What happens if I don't get that fellowship?

[Handsome88]

I'm in first year Med in Ireland. I'm planning to go into IM because I'm assuming (correct me if I'm wrong) it is a safe option for IMGs but it does not really help me out with my 250k+ debt. So I am relying on sub-specializing in Cardiology/GI, or going into Critical Care/Neurology after first year of residency for the higher pay.

 

So here are my questions:

 

1) What is the percentage of people that are able to clinch the top-tier fellowship of their choice?

2) What happens if I do not get that fellowship, can I re-apply again after practicing General IM for a couple of years? Or are we stuck with Gen IM forever?

 

I appreciate your help, thank you.

[Ollie]

Well the first step is to match back to IM in the first place which is not an easy feat. If you look at the CaRMS stats, there were 679 IMGs who applied for IM in 2010. http://www.carms.ca/eng/operations_R1reports_10_e.shtml

 

Assuming you do get in to IM, the fellowship match occurs during R3. Have a look through CaRMS for more info http://www.carms.ca/eng/r4_about_intro_e.shtml. Keep in mind that a lot of provinces have return of service agreements for IMGs.

 

To be honest I have no idea what happens if you aren't successful in the R4 match. From the looks of it you might be SOL unless there are unmatched spots.

[Guest copacetic]

some folks might do a chief resident year

[ploughboy]

or going into Critical Care/Neurology after first year of residency for the higher pay.

 

Neurology is not a branch of internal medicine in Canada. It is its own discipline, with it's own R1 match. Critical care (as already mentioned) is a two-year subspecialty that can be entered after R3.

[Handsome88]

Neurology is not a branch of internal medicine in Canada. It is its own discipline, with it's own R1 match. Critical care (as already mentioned) is a two-year subspecialty that can be entered after R3.

 

Assuming I do get into IM in the first place. How tough is it for an canadian IMG (graduating from one of the top 50 universities in the world) who did his residency in Canada to get a fellowship in:

 

Cardio

GI

Hem/Onc

Pulm/CC

 

Could you maybe rank them or give me an estimated percentage of Match rates for each?

 

Thanks.

[A-Stark]

I'd guess that the match rates are pretty high. I don't know whether IMG-status matters for the R4 match, but best to check the CaRMS website.

[justletmein]

I have heard from many residents and attendings that once you match as an R1, people no longer care where you went to med school.

 

When applying for fellowship, you will be a resident trained at X canadian university....

 

I think your biggest hurdle will be matching into IM in canada. Dont want to discourage you, but I think the numbers are deceiving.... you should probably apply to FM as well.

[gerd]

As mentioned already, where you went to med school becomes less of an issue when it comes to the R4 match, unless of course you signed some sort of ROS contract to get into a residency during the R1 match.

 

If you don't get your fellowship during the R4 match (which takes place early in your R3 year), you can never re-apply again. However, you can try and do your fellowship in another country after your GIM year.

 

It's hard for anyone to quote you a "percentage" because it depends on whether you apply across the country vs location-specific, and it varies from year to year. Having said that, I've heard that if you are flexible in terms of location, the acceptance rate for cardio is about 50%, but don't quote me on it. GI can be even more competitive in certain years just because of less spots.

 

There's no such combination fellowship as heme/onc or pulm/CC in Canada. Your options are either heme, med onc, resp, or critical care. The relative competitiveness again varies from year to year, but in general, resp would be the most popular.

 

Sounds like you're big on money, so GI, cardio and critical care would probably be your top choices. However, something to keep in mind is job availability, which is a big issue for these specialties in big cities. Another option to consider would be FP with some cosmetics incorporated into your practice.

[Steve-0]

I think you should think twice about picking a specialty based solely on income

[thebouque]

There's no such combination fellowship as heme/onc or pulm/CC in Canada. Your options are either heme, med onc, resp, or critical care. The relative competitiveness again varies from year to year, but in general, resp would be the most popular.

 

 

I agree with you that there is no combination such as resp + CC, but heme onc does exist in Canada (it's a 3 years subspecialty).

[Ollie]

I agree with you that there is no combination such as resp + CC, but heme onc does exist in Canada (it's a 3 years subspecialty).

 

Yeah but I think it's a sub-sub-specialty. In the R4 match the only options are either med onc or heme.

[Handsome88]

As mentioned already, where you went to med school becomes less of an issue when it comes to the R4 match, unless of course you signed some sort of ROS contract to get into a residency during the R1 match.

 

If you don't get your fellowship during the R4 match (which takes place early in your R3 year), you can never re-apply again. However, you can try and do your fellowship in another country after your GIM year.

 

It's hard for anyone to quote you a "percentage" because it depends on whether you apply across the country vs location-specific, and it varies from year to year. Having said that, I've heard that if you are flexible in terms of location, the acceptance rate for cardio is about 50%, but don't quote me on it. GI can be even more competitive in certain years just because of less spots.

 

There's no such combination fellowship as heme/onc or pulm/CC in Canada. Your options are either heme, med onc, resp, or critical care. The relative competitiveness again varies from year to year, but in general, resp would be the most popular.

 

Sounds like you're big on money, so GI, cardio and critical care would probably be your top choices. However, something to keep in mind is job availability, which is a big issue for these specialties in big cities. Another option to consider would be FP with some cosmetics incorporated into your practice.

 

Thank you for the information.

 

This brings up more questions. You said I will never be able to apply again if I don't get a fellowship in R3. What if I do my fellowship in the States or UK/Ireland (where I'm doing my medical studies now), can I come back and work in Canada? Or will I be in the same position as someone who did not do his residency in Canada?

 

I know I shouldn't pick based on income, but it is hard to not consider income when you have a 300k+ debt. Tuition in Irish schools are one of the highest in the world.

 

I don't know why people say that it is so hard for IMG's to match into IM. I thought it has a low competitiveness. Almost all Irish grads matched into their top choice, a lot are in IM.

[shannn]

Many physicians do their residencies in Canada and then do fellowships in the US before returning back to Canada (the majority of the attending ortho surgeons I work with did that). But the important thing is that they did their residency in Canada

[cheech10]

The problem with doing 3 years of IM in Canada and then a fellowship abroad is that IM is actually a 4 year program here, but your first fellowship year in Canada gets credited as your 4th year of IM. That's why you don't do your RC exams until after your first fellowship year. I don't think credit for this would apply for fellowships abroad, and is a major issue for US trained internists trying to come to Canada, as their programs are only 3 years long. I guess you could do the 4th year of GIM here (while it's still available, lots of talk of GIM moving to 2 year fellowship/5 year total training) and then do a fellowship abroad. That would probably work well, as going away for fellowship doesn't interfere with licensing for independent practice in Canada and is actually quite desirable for academic positions.

 

Someone mentioned earlier that there are no combined residencies any more (such as resp/ICU). Although that's true, you can still arrange them through the program directors directly, as long as they're both on board and the RC signs off on the proposed training. You typically need to find funding for the extra year though, which may be an issue for some programs. The way I did it was to match to the more competitive program first, then talk to the 2 program directors about proposed training, funding, and RC approval. It might be a bit more of an issue now with the formal R4 match and all.

[Handsome88]

The problem with doing 3 years of IM in Canada and then a fellowship abroad is that IM is actually a 4 year program here, but your first fellowship year in Canada gets credited as your 4th year of IM. That's why you don't do your RC exams until after your first fellowship year. I don't think credit for this would apply for fellowships abroad, and is a major issue for US trained internists trying to come to Canada, as their programs are only 3 years long. I guess you could do the 4th year of GIM here (while it's still available, lots of talk of GIM moving to 2 year fellowship/5 year total training) and then do a fellowship abroad. That would probably work well, as going away for fellowship doesn't interfere with licensing for independent practice in Canada and is actually quite desirable for academic positions.

 

Someone mentioned earlier that there are no combined residencies any more (such as resp/ICU). Although that's true, you can still arrange them through the program directors directly, as long as they're both on board and the RC signs off on the proposed training. You typically need to find funding for the extra year though, which may be an issue for some programs. The way I did it was to match to the more competitive program first, then talk to the 2 program directors about proposed training, funding, and RC approval. It might be a bit more of an issue now with the formal R4 match and all.

 

You got to be kidding...5 yr residency for a general IM? This is even worse than Europe. Would you at least be payed more in your 4th and 5th year...

[peachy]

Keep in mind that IM in Canada is very different from IM in the US. The way you've written about it as a safe option for IMG's makes me think that you're considering it from a US perspective. In the US it's a shorter residency and many (most?) grads end up in primary care. In Canada, Family Medicine fulfils the role that IM does in the US, and IM is considered much more to be a non-primary-care specialty.

[cheech10]

You got to be kidding...5 yr residency for a general IM? This is even worse than Europe. Would you at least be payed more in your 4th and 5th year...

 

Nope. There are ongoing discussions at the Royal College about this. The GIM guys (at the RC, not representative of everyone) feel that they're not getting the same level of respect as the subspecialists, and that lengthening the training program will correct this. As for pay, you would get paid at the PGY-4 and 5 levels, as you do in all other programs, so a raise of ~5,000 per year. I'm also not sure what would happen to moonlighting opportunities - currently you can moonlight in IM as a PGY-5, which adds considerably to your income, but if GIM went to 5 years, it's possible the RC could move the exam back to 5 years as well, eliminating everyone's ability to moonlight as an R5.

 

I would urge all IM residents to become resident members of the RCPSC. It's free, and hopefully they can get some input into this process.

[ploughboy]

I'm also not sure what would happen to moonlighting opportunities - currently you can moonlight in IM as a PGY-5, which adds considerably to your income, but if GIM went to 5 years, it's possible the RC could move the exam back to 5 years as well, eliminating everyone's ability to moonlight as an R5.

 

Presumably at least some of those R5s could go down the restricted registration pathway (http://www.restrictedregistrationontario.ca/) No idea if that's less lucrative than the current situation, but from my current position as a destitute non-internist junior resident I look at some of those job postings there and go "A thousand bucks for overnight in the ICU? Day-um, that sounds like good money!"

[cheech10]

Ploughboy,

Restricted registration is FAR less lucrative than outright moonlighting. An overnight call shift, in GIM or ICU, will make you 2 to 5 times as much, easily. Even more in very busy hospitals.

 

Brooksbane,

GIM has gotten a lot more competitive than it was, over the past few year. Toronto even had to turn down R4s from their GIM program. So it's not quite the default choice anymore; unmatched applicants have to cobble together their own program, which is more difficult to schedule and generally results in a less enjoyable year. And the pay in GIM is actually quite good now (on par with or exceeding most IM subspecialties), especially for those doing in-house call overnight in the community, with all the premium codes and stipends available. So I actually think that GIM will continue to increase in desirability and "prestige" over the next few years even if the RC does nothing.

[gerd]

I think it needs to be clarified that currently there are actually two different GIM streams, a 1-yr and a 2-yr one. The 1-yr GIM is what we refer to as the default one. That's the one you got guaranteed funding for when you matched into the IM residency. The 2-yr GIM fellowship actually requires that you apply to it, and can be competitive.

 

GIM is actually getting more and more popular for a number of reasons. Firstly, it takes less time to finish training if you choose to do the 1-yr GIM. Secondly, there are lots of jobs for general internists whereas it's becoming more of a problem for many IM subspecialties. Thirdly, the pay can actually be really good depending on what kind of practice you choose to have. Just as an example, there's an internist in greater vancouver who billed over 700 last year.

 

Here's some fruit for thought. If you decide to do cardio, that's 6 yrs minimum. If you want a job at an academic centre, you will need to do an additional fellowship of 2 to 3 years, taking you to a 8-9 year long residency. Compared that to 4 yrs for a general internist, who can do a lot of what cardiologists do if you work in the community. This was told to me by the above mentioned internist.

[Handsome88]

Keep in mind that IM in Canada is very different from IM in the US. The way you've written about it as a safe option for IMG's makes me think that you're considering it from a US perspective. In the US it's a shorter residency and many (most?) grads end up in primary care. In Canada, Family Medicine fulfils the role that IM does in the US, and IM is considered much more to be a non-primary-care specialty.

 

I'm not using it as a safety. I know how competitive the Canadian system is.

I just don't really like FM (no offense to anyone, just not my preference). And I really like both IM and EM...out of those two I think IM is the less competitive one and is the safer option-- correct me if I'm wrong. I've seen people from Ireland/UK match in ortho, gen surgery, psych, gyn..etc, if they can do it, why can't I get in IM?

 

I know I'm being optimistic here but I'm also hoping that they will open more spots for applicants in the next 5 years.

 

What MCCEE scores should I be aiming for? And lets be reasonable here...

[cardiomegaly]

You should be very careful with your optimism that they'll open more spots for applicants in the next 5 years

I say this because the Canadian med schools have faced various stages of expansion recently. Take U of A for example - the 2010 class had ~120 students, 2011 has ~135, 2012 has 155 and 2013 has 189. Calgary is similar. The alberta province grew 62 spots alone in one year. The Ontario schools have increased by smaller amounts but still 10-20 spaces.

The number of residency spots will have to increase to cover CMGs, and they will be very very hard pressed to do so. There's going to be a disproportionate jump in FM spots and IMGs are going to see a really big crunch in available spots pretty soon. Not saying it's fair, just that it's reality.

[thebouque]

I'm not using it as a safety. I know how competitive the Canadian system is.

I just don't really like FM (no offense to anyone, just not my preference). And I really like both IM and EM...out of those two I think IM is the less competitive one and is the safer option-- correct me if I'm wrong. I've seen people from Ireland/UK match in ortho, gen surgery, psych, gyn..etc, if they can do it, why can't I get in IM?

 

I know I'm being optimistic here but I'm also hoping that they will open more spots for applicants in the next 5 years.

 

What MCCEE scores should I be aiming for? And lets be reasonable here...

 

Honestly if you like EM you should consider the FM + EM R3 route.

[ploughboy]

Ploughboy,

Restricted registration is FAR less lucrative than outright moonlighting. An overnight call shift, in GIM or ICU, will make you 2 to 5 times as much, easily. Even more in very busy hospitals.

 

*boggle*

 

I can see why losing the opportunity to moonlight is concerning to GIM residents.

[Handsome88]

Honestly if you like EM you should consider the FM + EM R3 route.

 

Ya but that's kind of like cheating myself haha. Its more FM than EM...