The residency match needs to change—but not at the expense of international medical graduates
CaRMS season is in full swing: Every year around this time, anxiety paralleled with excitement hit fever pitch across the medical education system in Canada. It peaks on Match Day—which this year happened on Tuesday, February 26—when graduating medical students received the results of their application to the Canadian Residency Matching Service (CaRMS), determining where they will complete their post-graduate medical training and in what specialty.
And every year, students are left asking a damning third question: Will they get a residency position at all?
The shrinking ratio between candidates and positions available has resulted in calls for changes to the match process.
One commonly suggested solution is to exclude international medical graduates (IMGs), students who have obtained their medical degrees abroad, from consideration. The Association of Faculties of Medicine of Canada (AFMC) has called for IMGs to be considered separately from Canadian medical graduates (CMGs), limiting the pool of positions they can apply to (currently, they compete for the same jobs as CMGs do in the second iteration of CaRMS). There is an argument that these newly graduated doctors from abroad aren’t the responsibility of Canadian taxpayers, who subsidize the cost of training Canadian medical students.
However, such proposals require more nuanced discussion.
The matches not made
The CaRMS process is rigorous, arduous and stressful: Highly qualified students go toe-to-toe, vying for limited positions. Students are expected to determine their specialty of choice early and then put in the grinding CV-building work (academic excellence, research productivity, extracurricular and leadership activities) necessary for a competitive application. Last year, CaRMS reported that of the 2,980 CMGs who participated in the full match process, 172 went unmatched. Meanwhile, 1,360 of 1,758 IMGs went unmatched.
Most residency positions across Canada are allocated to CMGs. Just 326 of the 3,346 positions available in the first iteration (in which applicants and programs rank one another) of the 2019 match were earmarked for IMGs. Traditionally, all spots in the second iteration (which allows unmatched candidates to try to match to unfilled positions) are open to all applicants, including IMGs.
A 2010 CaRMS report determined that the number of Canadians studying medicine abroad had more than doubled in a five-year period to an estimated 3,500 in 2010, with 700 graduating per year. Over 90 percent aspired to return to Canada for residency training. We can only speculate that the number of Canadians studying abroad has continued to rise in the decade since this report.
These students are just like us, sharing our interest and passion for medicine. In fact, their commitment is so strong that that they pursue medical school abroad, at great financial and personal sacrifice. Though many of them have access to financial support from family, many also take on great debt. I have peers whose families have committed their savings, remortgaged their homes, and used numerous lines of credit options in pursuit of such dreams.
Privilege in the process
The fact that so many Canadians are studying medicine abroad reflects how difficult it is to get into medical school here.
According to the AFMC, there were 2,852 medical school positions available at 17 medical schools across the country in 2017–18. In 2018, the University of Ottawa had 4,293 applicants vying for 164 positions (an acceptance rate of 3.8 percent). That same year, the University of Toronto accepted 259 applicants, with an average GPA of 3.96.
In this hyper-competitive space, where a single grade or extracurricular activity can determine acceptance, privilege begins to show its face. Privilege in the application process is most apparent financially and socially.
Consider that most Canadian medical schools do not accept applicants who have ever studied part-time, effectively punishing students who may have commitments aside from their education (including employment). Such responsibilities can limit study time, ability to volunteer, or participation in research projects. Furthermore, lack of financial means is a barrier to hiring tutors, paying for Medical College Admission Test preparatory courses, or CV-padding experiences such as international work.
Lack of social capital is equally influential. Without friends or family in medicine, students may not see themselves represented in medicine, and therefore may not appreciate their suitability for a career in medicine until much later than their peers, if at all. Lack of social capital also prevents access to advice, support, practice interviews, application reviewers, and well-appointed letters of recommendation. It limits opportunities dependent on connections such as physician-shadowing or working with researchers.
Filling the need
Skepticism among Canadians regarding the quality of international medical education is common. But while the variability of medical education is a valid concern, IMGs must pass two Canadian licensing exams to be eligible for residency applications. Any further deficiencies in competency upon starting residency (which can equally exist between CMGs as it can between IMGs and CMGs) are addressed by the residency training itself.
IMGs are an essential part of the Canadian physician workforce. In 2016, one quarter (20,676) of physicians in Canada were foreign-trained. A testament to their contribution and competency is that we (often unknowingly) interact with them daily: as their patients, as our medical trainees and as our staff physicians.
IMGs frequently work in under-serviced areas in our country. More than half (53 percent) of physicians in Saskatchewan are IMGs, 37 percent in Newfoundland and Labrador, and 34 percent in Alberta. Furthermore, given that rural distribution of physicians is a major Canadian health care issue, IMG-allocated residency positions in the match often have return-of-service agreements. For example, IMGs in Ontario must work in specified communities for five years. International graduates have also been addressing our country’s need for more primary care physicians—over 60 percent of practising IMGs are family doctors. IMGs are also compensating for the moderate number of Canadian physicians leaving the country to practice abroad: since 2004, IMGs have ensured an annual net gain of physicians, including 58 in 2016.
The need for alternative solutions
Although each CaRMS season brings with it the unfortunate reality of increasing numbers of unmatched Canadian medical students, the answer to this perennial problem should not be solely at the expense of IMGs. Our unmatched students, both CMG and IMG, deserve the consideration of alternative solutions, and greater reflection into the country’s health human resource planning and strategy.
Maintaining positions for IMGs in Canadian residency programs partially addresses privilege by offering reprieve to those who were unable to gain admission to Canadian medical schools. Furthermore, it ensures a talent pool that has historically addressed the needs of the Canadian health care system.
Tarun Rahman is a family medicine resident at St. Michael’s Hospital in Toronto who previously worked as a public health epidemiologist. His writing focuses on global and public health, as well as issues of identity and culture.