Canadian IMG on the road back home: 2010

Going through the residency application process is stressful, and often times confusing – I should know, I have been there. As a Canadian IMG from St. George's University (SGU) who sincerely wanted to return to Canada for residency, I truly understand how daunting and discouraging the process can seem. In an effort to aid future applicants, I have detailed below some important areas of the application, which should help ease the process, remove some of the guess work – and most importantly help you acquire a Canadian residency!

First steps…exams and credentials!

Whether you plan on applying for residency training in Canada or the US, as a Canadian citizen, you must register with the Physician’s Credentials Registry of Canada (PCRC) in January of your third year (that is if you began in August). Getting a response from them takes a couple of weeks. This is essential to take the Medical Council of Canada’s Evaluating Exam (MCCEE), which is required to apply to the Canadian Resident Matching Service (CaRMS) or to get J1 Visa approval from Canada to train in the US. You may have heard about the H1B Visa as “ideal” and almost unconditional, however, you will need time off after you graduate to apply. US programs must provide sponsored funding for this; some programs will deny you an interview if you only choose to apply with the intent of getting an H1B Visa (but without actually having it yet). The J1 is accepted by more US programs, obtained through the Educational Commission for Foreign Medical Graduates (ECFMG), supported in part by your home country, and valid for up to seven years of training. It requires that you to return to your home country after you have successfully completed residency. You will only begin applying for the J1 Visa once you have matched to a residency program in the US. You can find out more about the J1 Visa on the ECFMG website.

You should take your MCCEE exam shortly after completing USMLE Step 2 CK (The MCCEE September dates in 2009 opened on September 8). So, if you plan on taking the USMLE Step 2 CK in August between your third and fourth year, take the MCCEE as soon as you can in September. Do not fear this exam! It is half the length of the Step 2 CK exam and the content is comparable. If you want some MCCEE oriented practice questions after completing your USMLEWorld Qbank for Step 2, you should try Canada QBank.

Padding that CV…

There are many books and online guides to help with formatting your CV for residency applications. I will only briefly cover what I feel are the most important aspects of the CV and what you should/should not include, what you may forget to include, and what will increase your appeal. Remember, no matter how you decide to organize your CV, keep the date formatting consistent and in chronological order (preferably most recent to least recent).

Research, Presentations – It never hurts to have at least one publication or presentation. It does not need to be in the same field to which you will eventually apply, but if possible, it should. If you have research experience, this should be at the top of your CV just after "Education" (list of degrees/post-secondary education). Even if your presentation and your publication pertained to the same topic, place the presentations under one section and the publication under another. If you have several publications and abstracts, list them under separate sections. Aside from scientific manuscripts, your graduate degree thesis (if applicable) can be placed under publications. Other things you may wish to include are newsletter/journal editorials you have published.

It is never too late to get involved in research. I went to grad school before medical school and had a lot of exposure to basic science research. Those of you that did not can get involved in basic science research during your basic science years of medicine. Approach a professor with whom you’re interested in working, and see how you can contribute to their current research efforts. If there is no lab available, some schools, such as SGU, for example offer surgical anatomy research opportunities using human cadavers through the Student Clinical Research Society (SCRS). In addition, there are also summer opportunities to pursue surgical courses at the University of Alabama at Birmingham. Surgeon-wannabes will benefit a lot from this, having previous surgical exposure when they enter their third year general surgery clerkship. I was fortunate and managed to get three publications out of my experience with the SCRS. During your clinical years, if you come across an interesting case in clerkship, express an interest in writing it up as a case report for your attending. These can be done fairly quickly and published in time for your residency application. Other options could be to approach an attending early-on in a field of interest and ask if there are research opportunities available. Sometimes, an eager student will encourage the attending to complete a paper they have already been working on, and get involved to help expedite the process. Don’t worry where your name goes on a paper - just get it on the paper! Some of these may lead to a presentation at a national conference or at the hospital’s resident research day. Be sure to let the attending know that you are willing to submit and present a poster at a pertinent conference. I am speaking from experience as I have completed two case reports and two presentations during my third core clerkship at NY Methodist Hospital in Brooklyn, NY.

Awards…

Keep these pertinent to Academics. Leave your black belt in karate for the skills section of your resume!

Awards could include any scholarships from undergrad, graduate or medical school; honour society, Chancellor’s/Dean’s List, teaching awards, research studentship awards, etc.

Membership in Professional Organizations…

Take a look at any attending physician’s CV (and not for its overwhelming length). I assure you this section will be on there. It’s never too early to join. The American Academy of Emergency Medicine (AAEM) offers free student memberships. The Canadian Society for Life Science Research (CSLSR) is for students of all levels interested in pursuing life science research (basic and clinical in both academia and industry). The CSLSR has very low membership fees, and provides members the opportunity to meet with potential mentoring physicians/scientists and the chance to present at an annual national conference. The American Medical Students Association (AMSA) is open to all medical students from WHO-approved medical schools. I would recommend joining any one or several of these to gain valuable exposure to your field of interest!

Extra courses complement your “skills”…

All those selectives you took during your basic science years of medical school you thought may be useless, are not useless at all. They may be great content for your personal statement or a topic of discussion during your residency interview, i.e. selective in radiology, head and neck, or that surgical anatomy course you took. If research was involved, put it under your research experience. BCLS, ACLS, PALS, and any other certificates pertinent to health-related courses should be placed under skills.

Complete this section by including any languages spoken (i.e. Fluent in English and French, some conversational Spanish).

Extra-curricular

As with all sections of your CV, your extra curricular activity should be limited to experiences you had as an undergraduate, graduate and medical school student. Since your entire CV should be no longer in length than 2-3 pages single-spaced, only include what you deem to be your most important extra-curricular involvements. Examples include, teaching assistant/tutor; executive/member of health-related organization; clinic or health fair volunteer; student council; journal editor, etc.

Hobbies and interests

List four things, which you love doing in your spare time. You will be asked about these in your interviews, so be prepared to speak about them in detail.

Choosing electives - especially the ones in Canada!

The CaRMS application will ask you to list your fourth year electives. Some like them broad, but you should do at least 1-2 in the field to which you intend on applying. Try and do them as early as possible, and at the place you would like to end-up for residency.

Visiting electives need to be pre-planned and you must apply early for these (6-9 months before the intended start date). This is one of the most important steps in your planning process, having Canadian experience will certainly add weight to your application, and will significantly increase your chances of getting interviews in Canada. Some schools, such as McMaster have quotas on the number of visiting elective students they take from each school. Others, such as the University of Toronto, only allow visiting electives between January-June. This isn’t helpful for those who began third year rotations in August, and have a full year of core rotations to complete by July 31 the following year. So make sure you invest the time to carefully plan, and select electives at Canadian universities, believe me this will pay off!

I would advise taking August between your third and fourth year off to study (for at least three to four weeks) for your USMLE Step 2, and to prepare your ERAS applications for September 1. You should submit your ERAS application for US programs, whether or not your goal is to return to Canada or stay in the US for residency.

McGill is one of the most accommodating places to get an elective. The catch-22 here is that, if you intend on applying to Quebec for residency, you must obtain a certificate of equivalence from the College des Medecins du Quebec (CMQ), which requires completing the MCCEE, MCCQE1, MCCQE2 and a French Exam (in addition to the USMLE steps). Realistically, this would take a full year or more to complete, and most medical students are not willing to wait that long. Why they require so much to allow IMG’s to train in their province is beyond me, but bear in mind that they also end up with more unfilled residency spots than any other province. Completing an elective in a specialty program at McGill is still very valuable; it allows you the opportunity to obtain a letter of recommendation from some of the most recognized Canadian names in the specialty. I did a neurosurgery elective at the famous Montreal Neurological Institute (McGill) with a world-renowned neurosurgeon/neuro-oncologist and he graciously provided me with a letter of recommendation. This ended up being a positive topic of discussion at some of my Canadian interviews for both Neurosurgery and Neurology.

While it’s important to acquire letters of recommendation from Canadian attendings for your CaRMS application, they may not be ready in time for your ERAS application. Do not stress too much about this unless you intend to use the letter of recommendation from an elective in Canada for your US residency applications. You will have until mid-late November of your fourth year to get these letters into CaRMS. Unlike ERAS for the US, the deadlines for CaRMS are not on rolling basis. Your ERAS letters should be ready by September 1 – so make sure you obtain letters from US attendings throughout your third year clerkship.

The best thing to do is research the dates of available visiting electives at each Canadian University on their medical education website (do a Google search for “visiting electives at McMaster or UWO” for example). Contact the school to see if they can accommodate more visiting students, or contact your prospective supervisor and if they approve, submit your application (some require an additional fee, which is well worth it). You should get a response within several weeks. In the grand scheme of things, the Canadian specialists will likely know others within their specialty, and you should not worry about where you do your elective in Canada, but rather with whom you do it. Any experience will be beneficial, even more so if you obtain a great letter of recommendation.

Why should we submit an application to ERAS and make sure it is submitted on opening day?

Because there are hundreds of programs in the US you can apply to for each specialty, and you have equal opportunity for all spots. In Canada through CaRMS, this is not the case. In the first iteration, you are competing against other IMG’s for a few designated spots (i.e. in 2010 there were ten IMG spots for Orthopedic surgery, five spots for neurology, one spot for Urology, one spot for Dermatology, and one spot for Neurosurgery). Although not a frequent occurence, some of those IMG spots remain unfilled (i.e. this year, many specialty programs at The University of Ottawa did not fill their IMG spots for unknown reasons).

It is unspoken, but, being Canadian (requiring a US VISA) and an IMG will put you at a double disadvantage when applying to competitive specialties in the US, i.e. Dermatology, Otolaryngology, Neurosurgery, Ophthalmology, Urology, etc. You may not get interviews at most of the programs to which you apply, but if you apply early, you will increase your chances because interview invitations are sent on a rolling basis. I found this out a little too late. It also helps to call the schools, sometimes an interview you may have intitally been denied opens up. I have a colleague who managed to get twelve Neurosurgery interviews by doing the above, and matched to a neurosurgery program in the US. The advantage of applying to US programs is that their interviews are held a few months earlier than Canadian interviews. Consider this “practice” for the CaRMS interviews and an opportunity to rank US programs, leaving more options open in case you don’t match to a Canadian program. This year, the CaRMS match results came out one week before the NRMP results. It will be expensive, but well worth it, I have colleagues who did get several interviews for IMG spots at Canadian programs this year, but did not match. They waited a week for the US results and matched to a great program. You may also be lucky (or unlucky?) enough to get a pre-match offer requiring you sign a contract with a residency program before the match results. In the US, this is done for IMG’s who impress program directors during their interviews (Canada does not offer pre-matches). This is great if you’re content with staying in the US and really like the program. I received a pre-match offer from an excellent university neurology program, but declined it, hoping to match in Canada. Some IMG’s may feel it is safer to take the offer, however, you are required by legal agreement, to withdraw from all matches if you choose to sign a contract for a pre-match offer.

Do USMLE scores matter in Canada?

This is truly unknown. One program director from the University of Toronto told me “they know what a good score is”. That being said, to some it may matter, especially if the score is high, i.e. 95-99 on a two-digit scale. You will be studying hard for the USMLE regardless and hoping that will translate into a good MCCEE score.

Personal statements

One of the things I truly believe helps the most in obtaining an interview in Canada, is strong evidence in your personal statement demonstrating your commitment to training in that particular specialty and in that particular program. The personal statement requirements are different for every program; you will need to check the CaRMS website to verify the necessary content (some have specific questions that must be answered in the body of your personal statement). Since there are limited programs for each specialty to which IMG’s can apply, you should take your time in putting your personal statements together. They should not be as generic as what you complete for the ERAS application (which does not need to be tailored for each individual program).

I got an Interview!

Once you receive an invitation for an interview, be confident and happy. In Canada, you are up against other IMG’s for the spot (with the exception of a few universities). There are so few spots and you should be proud you’ve gotten this far. The number of applicants vary every year and by program. These numbers are never as high as the US numbers (which makes perfect sense, since neither are the available spots, programs or population). You can search the CaRMS website for Reports and Statistics by year and they will list the number of IMG applicants for each specialty and the percentage of those that matched at all. Aside from primary care, the number of candidates invited for an interview is very small. This year, for one otolaryngology spot at the University of Ottawa, they interviewed three IMG’s out of forty applicants in the first iteration. For Neurosurgery, they interviewed six out of thirty-five applicants for one IMG spot. For neurology, it varied per school. Last year, they had over one hundred and forty applicants for only five IMG spots. To give you an idea of how variable the selection process can be from program to program, this year, for neurology, they interviewed six IMG’s at the University of Ottawa for one spot, ten IMG’s at the University of Toronto for two spots, and about twenty-six IMG’s at the University of Western Ontario for one spot. As previously stated, some spots do not fill at all, but most do. When it comes time to rank the programs, be sure to rank the programs as you want them, not how you may perceive they want you. The match is designed to work in the applicant’s favour (visit the CaRMS and NRMP websites to see how the match algorithm works).

I recommend reading "The Successful Match" by Katta and Desai (2009) for tips on how to prepare your applications and plan for interviews. Although this book seems to apply mainly to US programs, there are great tips that can definitely help when applying to Canada.

Why Canada vs. the US? It only matters if it matters to you. If you want to train closer to home and increase your chances at obtaining an attending position at a Canadian hospital down the road, then apply to CaRMS. No matter where you apply in Canada, you can be sure the training will be excellent. They are all major university programs (unlike many in the US, which are community hospitals), most of them being research intensive with consistent track-records of graduates obtaining competitive fellowships at top universities in Canada and the US.

There are a few setbacks, but since the recent opening of more IMG spots in the last few years, IMG’s, especially those at SGU, are well prepared for residency - giving them a lot to talk about, and the ability to convince the program directors that they deserve the spot. Those applying to Ontario should recognize that they must sign a Return of Service contract agreement, which indicates they must practice in an underserviced community of Ontario (as of 2010, this means anywhere outside of Ottawa or the Greater Toronto Area) upon completing their residency training in Ontario for up to five years. The good news about this is that those who wish to pursue community medicine will have a job available after they complete residency. If you wish to practice in the city, i.e. Ottawa or the Greater Toronto Area of Ontario, you can pay back $50,000 for each year of residency training to get out of fulfilling the return of service. Those who wish to pursue a career in academia do not have to serve in a rural/underserviced environment if they obtain an academic appointment at a university program, where 40% of their time is spent teaching. This is feasible, as most attendings at the University of Toronto, for example, are involved in training/lecturing medical and graduate students, as well as residents and fellows daily. Those wishing to verify this should contact the Ministry of Health and Long-Term Care. Also, unlike other provinces, those who complete residency training in Ontario are eligible to sit for the Royal College of Physicians and Surgeons exams without taking the MCCQE1 or MCCQE2 during residency, provided that they passed all three steps of the USMLE. The buck doesn’t stop there! Should you obtain a residency in Canada as an IMG, prior to commencing your residency program, you will be required to complete one month of pre-residency training with the Centre for the Evaluation of Health Professionals Educated Abroad (CEHPEA), which provides services to internationally educated health professionals including standardized evaluation and orientation programs and assessments for direct entry training in Family Medicine and other specialties.

If you ask me, it’s all worth it in the end. It is important to remember, you must be happy where you train for residency – ideally, with both the program and the location. You may be there for a long time!

This may all seem overwhelming, but, if you truly wish to return “home”, it can be done! I can only imagine as more of us compete for and successfully obtain residency positions in Canada, more doors will open for other Canadians who have temporarily expatriated to attend medical school abroad. This year, aside from me obtaining neurology at the University of Western Ontario, fellow SGU grads obtained Canadian residency positions in Pediatrics, Ophthalmology, Internal Medicine, Family medicine, and Dermatology. Last year, we also had a student match to Orthopedic surgery.

If you put in the time, effort and commitment, it can be done! Although there are few resources out there for IMG’s who want to pursue residency training in Canada, I hope this piece helped to clarify the process. I am committed to helping medical students fulfill their goals, and hope to welcome many more Canadian IMG’s “home” in the future. Good-luck!

- Phil

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