Acronyms & Defintions
What does SOCASMA stand for?
Society of Canadians Studying Medicine Abroad.
What is a CSA? A Canadian studying medicine abroad, ie, outside of Canada or the U.S.A. CSAs are international medical graduates (IMGs). Most CSAs are Canadian born and raised and educated in Canada. Many have a Canadian university undergraduate degree. Almost all attend English speaking medical schools with the majority attending schools in England, Scotland, Ireland, Australia, New Zealand, and the Caribbean.
What is a CMG? A Canadian or American medical school graduate.
What is an IMG? An international medical school graduate.
What are the other acronyms I should know about?
CaRMS – Canadian Resident Matching Service
CPSBC – College of Physicians and Surgeons of BC
ECFMG–Educational Commission for Foreign Medical Postgraduates (American institute)
FOM – Faculty of Medicine
LCME–Liaison Committee on Medical Education (U.S.A. accreditation body)
MCCEE – Medical Council of Canada Evaluating Examination
NAC – National Assessment Collaboration
NBME – National Board of Medical Examiners (U.S.A.)
NRMP–National Resident Matching Program (U.S.A.)
OSCE – Objective Structured Clinical Examination
USMLE – United States Medical License Exams
What is a medical resident? After medical school, graduates have to work in training positions called medical residencies before they can become fully licensed. They are hired by the provincial Ministries of Health to work as resident physicians, ie, apprentice physicians. Resident physicians are an important cog in the medical wheel. They are not the most trained or knowledgeable, but they work the most. They work as much as 80 hours per week. They examine patients, take medical histories, reach diagnoses and prescribe treatment, under the supervision of medical staff. The supervisor is not present during the majority of the time they are in direct contact with patients. They write orders for treatment and prescribe drugs. They face life or death situations. Resident physicians take on more and more complex work and responsibility as they gain experience. As they approach the end of their residency, there is little to distinguish what they do from what their designated supervisors do.
Who controls the residency selection process? Residency selection determines who will be able to practice medicine in Canada. Since 1993, the Ministries of Health and the Provincial Colleges of Physicians and Surgeons have allowed the Canadian universities to control residency selection. In 1993 the universities took control of training all new physicians. The universities organize Canada’s licensed physicians to provide on-the-job-training for medical graduates.
Has the residency selection process always been the same? Up until just over 10 years ago, all residency positions in Canada were open to competition by all qualified Canadians. After the universities of Canada gained full control over residency selection and training in 1993, province by province, they created a system of competition for residency positions that basically guaranteed their graduates medical jobs, at the expense of other qualified Canadians. To secure training jobs for their graduates, the universities changed the rules and got rid of the competition. Canadians who chose to study at international schools and immigrant physicians (IMGs) are no longer allowed to compete against CMGs, until after CMGs have their choice of residency positions. The Canadian universities created a separate stream of competition for IMGs. This is a stream with very few positions and little opportunity. To make things even more uneven, all IMGs who want to compete in the IMG stream must sign a contract, which provides that the IMG has to work where the Ministry of Health tells him to work, after he completes his residency training. If the IMG dares to breach the contract, he has to pay $108,000 for each year of residency which sum is more than the education component and the resident’s salary and benefits for work performed combined. The new rules, developed by the universities puts no obligations on CMGs who are subsidized by the taxpayer. The last university to change its rules from a merit based system to this new protectionist system was the University of Manitoba. It changed to these new rules after 2012 when a significant number of their own graduates lost the competition for jobs to IMGs.
What does a first class and second class competition steam look like? We will use B.C. as an example:
I. CMG (Canadian and American Medical School Graduate) stream in 2013:
*CSAs and other IMGs can only compete for leftover positions after CMGs have completed their first round (iteration) of competition.
- 274 residency positions :
- 107 family medicine residencies
- 167 specialty positions
- 256 UBC graduates
- 252 UBC graduates applied for residency in Canada.
- 140 UBC graduates stayed to work in British Columbia residency positions.
- 16 Leftover positions after first round (iteration)
- Competition as of right
- No return of service obligations. This is true even of those medical school applicants who entered UBC medical school with low MCAT scores and GPAs as low as 70% because UBC considered them good candidates for rural practice.
II. IMG (International Medical Graduate) stream in 2013:
- 28 family medicine residencies
- 6 specialty positions in 3 out of 64 recognized specialty disciplines: psychiatry, internal medicine, pediatrics.
- Ability to compete is contingent on agreeing to return of service obligations.
- Preference of immigrant physicians over CSAs. (Number of CSAs who have been successful is not available as all bodies have refused to provide this information. Few succeed in BC.)
Before 2005 there were a total of 6 residency positions in the IMG stream.
Why are IMGs not eligible to compete against CMGs for positions in the first iteration of the CMG stream of CaRMS?
In a briefing document dated December, 2011 UBC, the BC Ministry of Health, and the BC Ministry of Advanced Education provided two explanations:
- “Canadian Medical Graduates (CMGs) also compete for residency positions and expect to be able to complete medical education, and become eligible to be licensed to practice medicine in Canada. The common practice therefore is to ensure that the national number of residency positions in the first iteration of the CaRMS will be equivalent to the number of students graduating from medical schools across Canada.”
This is hardly a justification. All graduates of professional programs want to be able to complete their postgraduate professional education and training so they can be licensed to practice their profession in Canada. To expect to be handed a postgraduate training position reflects a culture of entitlement among CMGs which should not be encouraged. The principles of Canadian society and fairness require that the best qualified Canadian candidates fill the postgraduate positions if there are an insufficient number to accommodate all.
- “Medical schools outside of Canada and the United States are not measured against the same accreditation standards; therefore, those applicants that did not complete their undergraduate MD education in Canada, must demonstrate their competence to be eligible to compete for residency places in Canada.”
This also falls short of a justification. This explains why international medical graduates must pass the national MCCEE and NAC OSCE which are designed to establish that they“are at the level of a Canadian medical graduate entering postgraduate training.” This provides no justification for IMGs who have proven their competence by passing this exam being precluded from competing for residency positions against CMGs in the first iteration.
Isn’t it in the public interest to make sure that our medical school graduates get jobs?
Some people think that enabling CMGs to get postgraduate training is necessary to capitalize on tax payers’ investment. This argument may appear appealing at first glance but careful consideration will likely lead to a conclusion that a merit based selection process involving all qualified medical graduates best serves the public interest.
- If “taxpayer investment” was an acceptable argument, all professions that require postgraduate training should be preferring Canadian university graduates over all others. All professional education programs cost the taxpayer money. Most professional graduates require postgraduate training before being eligible for independent practice. Selection for postgraduate training positions is based on merit in all professions but medicine. Canadians who chose to study overseas are free to compete against Canadian school graduates in all professions but medicine. Nobody fusses over the Canadian university legal graduate or accounting graduate who cannot get an articling position. Similarly with architecture, engineering, geoscience, veterinarian medicine, and every other profession but medicine. The taxpayer wants the best Canadian candidates to advance, regardless of what school they attended. When the taxpayer’s loved one needs medical attention, a taxpayer wants the best medical doctor. The reason that medicine stands apart from any other profession, is not because of any public policy interest, but because the universities which were put in control of postgraduate training in medicine have chosen to promote their own interests.
- The public interest is best served by hiring the most qualified Canadians for the job. The current system does not allow the most qualified Canadians to be hired as resident physicians. The problem is best exemplified by a quote from Wikipedia in reference to Rhodes scholars, “For more than a century, Rhodes scholars have left Oxford with virtually any job available to them…. They have reached the highest levels in virtually all fields.” Not in Canada. Canadian Rhodes scholars are not welcome back to compete for the “highest levels” in medicine. They are delegated to the second rate IMG stream where, in B.C., for instance, they can aspire to only 4 of 65 medical disciplines.
- A system which is not merit based results in compromised quality of care.
- A system that entitles CMGs to enter medicine, and discriminates against IMGs, is inconsistent with the principles of a free and democratic society. A free and democratic society does not limit the ability of qualified Canadians to advance in the most prestigious calling in Canada, because they did not study at a local school. Determining advancement and opportunity on the basis of the school one attended is a throwback to the old English class system which has long ago been rejected.
- Having a two class system of access to the medical profession breeds a sense of entitlement among some and prejudice against others. This is harmful to society and to the medical community.
- The value of an international education is recognized as an asset to society in today’s globalized world. For example, the B.C. Ministry of Advanced Education’s current Service Plan has an objective to develop a highly internationalized education system which includes expanding “opportunities for B.C. students to participate in study and work abroad experiences to gain knowledge and build relationships that will enable them to be successful in an increasingly global society.” The Plan goes on to state: “The province is also becoming more culturally diverse. We need to expand our international focus in B.C. to remain competitive in an increasingly globalized world. This will lead to greater understanding and tolerance, enriching personal connections between British Columbians and other people around the world. It will also help create and maintain key international pathways for commerce, research and innovation.”
- The current system which allows the universities to make the rules and select resident physicians has implications for public safety.
- Failure to require the standard national examinations for all medical graduates, allows CMGs who may not have the requisite knowledge and skills to enter the practice of medicine as resident physicians.
- It is consistent with public safety to require that all IMGs prove their medical knowledge and clinical skills before being allowed to compete for medical residency positions. The universities in charge of residency training do require all Canadian IMGs to write these national examinations.
- Canadian universities sell residency positions to foreigners from oil rich country. UBC, for example, charges up to $75,000 per year per resident position, for a total of $7.13 million in sales in the 2012/2013 year. UBC doesnot require these foreigners to pass the national medical knowledge and clinical skills exams to be allowed to practice medicine on the B.C. public. (Canadians cannot buy their way into residency positions in B.C.; only foreigners from Middle East countries can.)
- The current system which allows the Canadian universities to make the residency selection rules to serve their own interests is a barrier to solving the medical doctor shortage in Canada.
- The universities use Canadian doctors to train foreigners, reducing capacity to train more Canadian doctors who have medical degrees.
- Access to inexpensive medical care provided by resident physicians is not being capitalized upon.
- Highly skilled and educated CSAs are being forced to emigrate resulting in a brain drain of a much needed resource.
- The inability or refusal to train more Canadian doctors results in increased government spending recruiting foreign doctors, attempting to relocate and redistribute practicing doctors, and restructuring and increasing fees in an attempt to retain doctors who may be enticed to leave Canada for better pay.
Why do CSAs study abroad?
Are CSAs and their families fully aware of the barriers to resident positions when they choose to study medicine abroad?
No. In December 2011, a briefing document released by the Ministry of Health, the Ministry of Advanced Education, and UBC’s Faculty of Medicine stated they were aware of this lack of knowledge. The brief states that CSAs “believe there is a shortage of physicians in Canada, and there will be opportunities for them to return to Canada to practice medicine.” The brief states that it is UBC’s commitment to work with government and key stakeholders to improve communications to ensure that those considering medical education abroad are fully aware of the facts before making their decision.
Do CSAs study abroad because they cannot get into Canadian medical schools? Some yes. Some no.
1. In 2010 the CaRMS CSA survey reported:
- 26.7% of CSAs have never applied to a Canadian medical school
- 37.0% of CSAs applied only one time to Canadians medical schools (The survey results do not set out how many CSAs applied to both, Canadian and International schools, at the same time, nor how many were accepted to Canadian medical schools but chose the international school.)
- CSAs applied to Canadian medical schools an average of 1.76 times
- CMGs applied an average of 2.95 times before being successful
2. In 2013 the Canadian Medical Students in Poland reported that only 2.6% of Polish students chose to study in Poland because they could not get into a Canadian medical school. However, 27.63% stated they did not want to risk not getting into a Canadian medical school. The most common reason was that Poland offered a medical program that was high quality and time efficient. The second most common reason was a desire to explore the world. The third most common reason was lower tuition fees.
Do CSAs pay substantially higher tuition for medical schools?
The average annual tuition cost ranges from $12,250 (CDN) in Poland to $66,369 (CDN) in Australia. Some CSAs chose to study abroad because tuition costs were lower than Canadian medical schools. (Source: 2010 CaRMS survey)
Are CSAs less qualified to practice medicine than CMGs?
In all probability some are less qualified, some are equally qualified, and others are more qualified.
- National medical knowledge and skills (MCCEE) and clinical skills (NAC OSCE) examinations are designed to ensure that IMGs including CSAs have the knowledge and skill necessary to work as resident physicians. A passing grade establishes that the IMG’s knowledge and clinical skills “are at the level of a Canadian medical graduate entering postgraduate training.” Thus every IMG who writes and passes the NAC OSCE and the MCCEE has proven that they have the medical knowledge and clinical skills of CMGs.
- Comparing how any individual CSA compares to a CMG is more difficult.
- In the USA, everyone, regardless of the medical school attended, regardless of citizenship, has to write the U.S. medical licensing exams. (SOCASMA has members who have scored in the top 2% of all medical graduates writing these U.S. licensing examinations.)
- Canadian and American medical school graduates are not required to write medical licensing exams, which makes it difficult to compare CSAs and other IMGs to CMGs. In the current system the knowledge and skills of medical graduates need not be examined as Canadian universities have designed a system that virtually guarantees their graduates training jobs as resident physicians regardless of how well or poorly they did in medical school.
- Canadian medical schools do not all issue grades. UBC courses, for instance, are pass/fail. Thus it is not possible to compare CSAs and CMGs by their grades or how they ranked in their class because CMGs do not get grades.
- A comparison of the reputations or international ranking of a school is another way of evaluating the quality of the medical graduate. This, of course, is a poor substitute for evaluation on the medical graduate on individual merits. Assuming a reputable school in a developed country, how well a student masters the education (s)he accesses is more a function of individual motivation, aptitude, and work ethic than the medical school itself.
- A review of the international ranking of medical schools demonstrates that Canada does not have any medical schools ranked in the top 10. Some CSAs attend medical schools that are ranked internationally higher than any Canadian school. Most CSAs attend medical schools that are ranked higher than the lowest ranked Canadian medical school.
- The quality of medical education in Canada is controlled by a Canadian (CACMS) and American (LCME) accreditation organization. Canadian medical schools have been put on probation by the American accreditation organization on various occasions. Currently the University of Saskatchewan is at risk of losing accreditation.
- The Colleges of Physicians and Surgeons of Canada in determining registration qualification recognize medical degrees that are awarded by medical schools recognized by FAIMER (Foundation for Advancement of International Medical Education and Research). All CSAs attend medical schools recognized by FAIMER.
- Some people, often Canadian medical school students, claim superiority to CSAs on the basis that CSAs were not accepted into a Canadian medical school. To quote one who posted on a medical chat line: “IMGS should be treated as second class medical graduates. That is by definition what they are. They could not get into a Canadian school because they were not good enough. That is why they went abroad and bought their degree. Why in the world should they be on the same playing field as CMGS? They are not in the same league?”
- 63.7% of CSAs never applied to a Canadian medical school or applied just once. 26.7% never applied at all. The average CMG applied 2.59 times before being admitted to a Canadian medical school.
- Even if a student was not accepted by a particular university, it does not mean that they would not make an excellent physician. University admissions do the best they can, but they hold no crystal ball. The best measure of success is success itself. Each level of challenge helps separate those who wilt from those who thrive, the poor and mediocre from the best.
- Canadian universities do not have a uniform admissions policy. Students were admitted into UBC medical school with grade point averages as low as 70% and poor MCAT scores. UBC admissions determined that lower scores were warranted in students that they identified as good candidates for rural practice. CBC reported in 2012 that only 25% of the students who were accepted into medical school as rural candidates in fact stayed to open practices in rural areas. Thus, UBC’s success rate in identifying good rural candidates was 25%. CSAs have entered medical schools with GPAs as high as the 90s. SOCASMA is unaware of any CSA accepted into an international medical school with a GPA as low as 70%. SOCASMA members have had MCAT scores as high as the 99.7 percentile.
- Doctors who have served on UBC Admissions have advised SOCASMA that there are many more excellent applicants for medical school than there are positions, and there is a point in the selection process as it narrows where it is basically arbitrary as to who is accepted and who is not.
- As volunteering is an important part of medical school admissions criteria, some Canadians from financially challenged families had to work, with no time left for volunteering. Similarly some Canadians who had disabled or otherwise dependent family members could not volunteer. These Canadians were disadvantaged in the medical school competition process.
- Some of these Canadians also find it necessary to find medical schools that are reputable, but more affordable to realize their dreams and aspirations. A medical degree can be obtained more quickly and cost effectively through medical programs that are designed to begin after high school.
- An examination of the facts suggests that there is no basis for concluding that CMGs will make better doctors than CSAs.
- What an examination of the facts shows is that when Canadian universities exercised their control to bar IMGs from competing against CMGs, they created a breeding ground for a sense of entitlement on the part of CMGs, and prejudice against IMGs. By refusing IMGs the opportunity to compete against CMGs, and reducing them to a second class stream, the universities have put a ceiling on how high Canadians who exercised their freedom to experience the world, and immigrant physicians who came here to find a better life, can aspire in the medical profession.