The North American Experience

“You are going where? There is no future for doctors from abroad in Canada!” That’s what many people said before I arrived in Canada as an International Medical Graduate (IMG) from Pakistan. When I first set foot in Canada with my family in 2016, I was very confused – mainly because Canada’s residency application process, the required exams, and the process for IMGs to become accredited in the healthcare system are not well known. Here, I try to shed some light by comparing the postgraduate medical education in Canada with the better-known US system.

Residency: the two systems
 

Canada has a universal healthcare system, which technically guarantees free healthcare for all. This concept trickles down to medical education as well as residency training, which is all funded by the government. Seventeen medical schools in Canada (1) and 154 medical schools in the US offer an MD program, with a further 38 DO or osteopathic medical programs available in the US (2, 3). (Despite its size, Canada has a much smaller population, which partly explains this huge difference.)

Many students who apply for residency in Canada are either Canadian Medical Graduates (CMGs), IMGs or Canadians Studying Abroad (CSA; it’s worth noting that some people do not agree with this term). CSAs are Canadian students who study medicine abroad and after graduating decide to come back to do their residency in Canada. The Canadian residency matching is administered by the Canadian Resident Matching Service (CaRMS), which is quite similar to its US counterpart, the Electronic Residency Application Service (ERAS). However, unlike the US, which has a set number of residency spots and allows for a competitive match whether for US medical graduates or IMGs, CaRMS has different streams for applicants. The stream with the highest “quota” of seats is the CMG stream, followed by a “regular stream,” which accepts both CMG and IMG applicants. A specific IMG stream also has a quota. There are a few other streams, but the ones above are sufficient for this comparison. The quota system has its own benefits and drawbacks, the benefits being that IMGs are guaranteed a specific number of spots every year and have specific requirements that they fulfill for those. Most of these “quota” seats are in primary care with less seats allocated to more competitive specialties. The main drawback is that IMGs lose a huge chunk of seats that they cannot even compete for and many end up not applying for hard-to-get specialties despite having exceptional resumes. In comparison to the US, where the ground is open for all; IMGs can apply and compete for the same spots as American graduates. Another limiting factor in the application process is the visa status; since in Canada one factor is that in most cases the candidate has to be either a citizen or permanent resident of Canada (exceptions exist for some self-sponsoring candidates) while that is not the case in the US; anyone from the world can apply and will be given visa sponsorship which facilitates the immigration and integration process for many. 

What about licensing exams? The US has the very well-known USMLE – a rite of passage for all medical graduates. These include – in short – USMLE Step 1, 2, and 3. Canada has similar licensing exams, including the Medical Council of Canada Qualifying Examination Part I (MCCQE1) and the National Assessment Collaboration examination (NAC OSCE). There used to be two more exams, the Medical Council of Canada Evaluating Examination (MCCEE) and the Medical Council of Canada Qualifying Examination Part II (MCCQE2), but these were recently terminated (4). 

A few years ago, there was a dearth of information about preparing for these exams, with many students resorting to USMLE resources to prepare which always used to fall short since many screening guidelines are different in Canada as well as the thresholds and units for many lab values (since Canada follows the British system). Now many study groups and online resources as well as review books are now available for reference (5, 6, 7, 8); however, there are many more resources for the USMLE. The Canadian exams are very heavy on ethics, and students find these chapters lacking in their regular textbooks; however they gain extensive practical experience during their electives and observerships.

Application process and profiles
 

Many applicants have research or observership experience on both sides of the border and, as I have seen, the experience is fluid across the border for either CaRMS or ERAS. Having served as an Instructor at the Ontario IMG School in Toronto, I conducted lectures and training sessions for students for their Canadian and US licensing exams (9). I have seen many success stories on both sides of the border, with many students planning to simultaneously go through both US and Canadian exams given that both curriculums are similar. Having said that, based on my students’ experiences and from the data available, I have found it is much easier to match in the US than in Canada. In 2022, the number of available pathology residency spots in Canada was around 15 (10). In the US, there were a total of 631 pathology residency spots – 274 of which were occupied by IMGs (11). Moreover, those applying for residency in Canada must be a permanent resident or a Canadian citizen – an important prerequisite that does not exist in the US, where applicants can apply regardless of their legal status (12).

When IMGs leave their home countries and migrate to other places in search of more learning or a better future, they must be prepared for difficult waters. My advice to students who are navigating through the application process in both countries is simple: Express genuine interest in what you want to do in the future. The US and Canada are both amazing places to learn and grow, with great opportunities in research. As a pathology residency applicant, the most important aspect of your application after your exam scores (whether taken in the US or in Canada) is relevant experience in the field and a passion for pursuing pathology.

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