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I’m a Canadian currently backpacking through the UK. I just left London. Here’s a quick summary of the ten most important things I learned along the way.(This will mostly be applicable to those looking to travel on a budget. All costs in USD.)[EDIT: Came back to this in early 2020 with a few updates. I’ve since spent more time in London, and my thinking has shifted a bit on some points.]#1: CityMapper is your friend.It’s the best app out there for local transit. Just trust me. Download it before you arrive.You can also use Google Maps while walking aboveground. You don't need cellular data (GPS is a separate system). But you should download local maps for offline use if you want navigation help.#2: _theCloud is your friend.Assuming you don't have a UK SIM and aren't interested in paying roaming fees, finding reliable wifi is key._theCloud is a public network you can log onto at every Caffe Nero, Costa Coffee, or Pret et Manger (all pretty ubiquitous across London). Once you give them your details, you can use the network wherever it's available at no cost.Starbucks also has its own wifi service that runs separately in many stores (which are also everywhere).Most museums and libraries have free admittance and wifi, but you'll find that most parks and transit stations are without. (In a pinch, you can access pay-per-use O2 or Virgin hotspots pretty much anywhere. They're just really pricey.)[2020 EDIT - I was unaware of how cheap short-term plans are on good travel SIMs. While knowing how to get free wifi is handy for limiting your data use against said plans, I would definitely recommend a SIM. For this trip I paid about $30 for a Vodafone package that gave me unlimited texts, 1k minutes, and 30gb of 4g data Europe-wide. No contract or hidden fees, and the package last 30 days. Plus it gives you a UK phone # to sign up for apps that require a local number. The only downside is that you won’t receive any calls/texts to your regular number unless you swap SIMs or use iMessage.]#3: CouchSurfing (the app) is your friend.Choose between it and Airbnb based on how social you want to be. Couchsurfing is better if you're looking for people to explore with, though you have to be more flexible to their schedule(s).A few pointers:Message potential hosts before doing a stay request. Address their interests first, not your needs. Read the specifics in their bios. Mention at least one.Be mindful of paying for verification. Couchsurfing is not forthcoming on pricing (it was about $50 USD). Arguably worth it, but very sketchy payment process.Get references from friends. This is especially necessary if you aren't paying for verification.Make sure to fill out your bio with interests and personality fit details.Don't book too far in advance if you aren't ok with cancellations. A week or so out is generally ideal.Couchsurfing doesn't cost anything beyond what you voluntarily spend on your host. A cheap Airbnb anywhere near central London will be $50 or more. (On weekends often a lot more. Though you can save money by staying on the outskirts and then just commuting in each morning.)Hostels are a middle-ground option (often only $25–$35 in great locations), but don't always offer private rooms. If you’re going to stay in one, book through booking.com or Agoda. Both are free, quick, and likely to get you the best rates. But pay attention to reviews. Stay at < 7.5/10 options at your peril.#4: Be smart about local travel.Get your Oyster Card (prepaid tap card for the London transport network, including buses, local rail, and the underground) within the airport at the information desk upon arrival.You’ll pay a straight £3 instead of a refundable £5, but it looks pretty cool and you’ll spare yourself a much longer line. (Just one person in front of me at the Gatwick info desk compared to 109+ people in line at the connected station that takes you into London.)Taking the tube can add up, depending where you're going (the fares are based on zones and run about $3 per go for Central London — though there are daily caps equal to three fares). Plan your trips based on neighbourhoods. Often plenty of things to see within a very walkable radius, especially in the central areas.When taking the tube, finding the right train means identifying: (1) the name of the line you're taking, (2) the cardinal direction you're going, (3) the terminal point of the specific train. Easy to get lost if you aren't paying careful attention to all three.[2020 EDIT: If your credit card is tap-eligible, you can just tap that directly on the Oyster reader. It charges the same as an Oyster card fare, which is like half the cost of a single-fare ticket from the machine. It also automatically applies the Oyster cap, so you’ll never pay more than three fares per day regardless of how often you use it. It also has a weekly cap equal to the Travelcard, which is an unlimited one-week Oyster card. The only difference is that the credit card cap runs Sunday to Saturday, where the Travelcard is 7 days from when you activate it. All said, I find the credit card option best. You don’t need to ever buy anything or manage an extra card in your wallet. Just don’t forget to tap out every time you finish a trip!]#5: Bring a water bottle.Public drinking fountains are comparatively rare. While there are many public bathrooms (called toilets on the signs) where you can refill a bottle, you’ll often be looking for a fountain in vain unless you planned your route accordingly.(Nearly every park has little cafes or snack stands. But the prices for drinks are cartel-like. A can of Coke can run you $2-3.)[2020 EDIT: Many have pointed out in the comments that most licensed restaurants and food vendors need to give you a free refill if you ask, even if you haven’t purchased anything. That seems a bit awkard of a request to me personally, but obviously/thankfully not everyone is me. Anyway, someone also pointed out this cool app that shows refill locations: Find water on the go.]#6: Don't be afraid to wander.Throw out your tourist maps. Just pick an area and walk around. You’ll find some amazing shops and sites in odd locations, tucked behind other buildings and down random alleyways. (As a rule, the rents for stores on main drags price out all but the largest brands, leaving lots of the cool local stuff a little off the beaten path.)As far as safety goes, obviously be wise at night. I found central London really safe, but I'm also a dude and pretty huge.(Above: a cinematic walkway I stumbled upon near Temple Church.)(Above: the view of St. Paul’s Cathedral when approached through side-streets, which really caught me by surprise.)Speaking of which…#7: Skip the London Eye and go to St. Paul’s.You're a bit lower (365 feet vs. 443), but it costs less (only $20 for a yearlong pass if you book online) and gives you amazing open-air views.And that isn't to mention how beautiful the cathedral is inside. (I spent about 3-4 hours and wish I had stayed longer. Lots to take in.)Just be prepared to make a climb if you want the views. 528 steep and narrow steps to the top (divided into three flights, each tougher than the last). Not for those with vertigo or bad hearts.[2020 EDIT: You can get into St. Paul’s for free if you go during a public service. There are just some restrictions on wandering. Personally I would just buy the year-long pass online. But if you’re only looking for a quick sense, or if you’re bringing kids along, this can save you a bit.]#8: Go see the museums.As mentioned above, most of them are free to the public. Great places to explore or hang out. Plus you can perch and write in most of them.I particularly enjoyed the Victoria & Albert Museum in Kensington (has a wonderful Raphael exhibit and plenty of great Renaissance works).The National Gallery (adjacent to Trafalgar Square) usually has some interesting things happening out front.(I'm not entirely sure what this act was about. But I showed up just in time to snap a cool pic.)#9: Seriously, mind the gap.There's a reason they repeat the phrase every two minutes on every train. The gap can be surprisingly large at times and you can easily hurt yourself.On the same subject, there's a reason they have pavement markings with arrows that say “look this way” at almost every road crossing. It's really hard to adjust to looking for traffic from the opposite direction than you're used to! If I never make it back to Canada, this will be why.Also, as a point of etiquette, you should always stand to the right on escalators if you aren't walking. Locals more concerned with making a specific train will get testy if you're standing in their way. (Most staircases are split by a rail. Always walk to the left of it. Slower walkers generally keep to the middle, leaving room for hurried folks to pass on the far left.)#10: Neighborhood grocers are your friend.Food in London isn't cheap. At least not in terms of the more popular restaurants and cafes. But there are budget options.First, you have express-size versions of the major supermarket chains everywhere (Sainsbury’s, Waitrose, Tesco, M&S). All have really solid deli options. I found the price and quality refreshingly high compared to most of what I've eaten in North America.You also have plenty of non-brand cafes (often ethnic). If you look around just off the main strips, plenty of places where you can get a full English breakfast or decent dinner for like $10-$12.For breakfast or lunch, bakeries are often your best bet. You can generally get an americano and bacon roll for $5 or so. (Warning: you can't really find normal drip coffee here, and the bacon isn't bacon in the sense we think of it — though don't let that hold you back from enjoying.)[2020 EDIT: I forgot to mention this previously, but all those grocers have a thing called a Meal Deal, which is a UK-wide staple. For something like £3 you get a sandwich/salad/pasta/wrap and a beverage and a snack. Applicable items usually have stickers marking them, and automated kiosks apply the discounts for you. The variety and quality of the entrees is actually quite good. And if you go in the evening those entrees are marked down by as much as half. I often bought them and ate them for lunch the next day and noticed zero taste difference.]Have fun!Oh, one last 2020 edit.Unless you’re a business traveller or otherwise in a real hurry, I wouldn’t bother with the express trains from Heathrow or Gatwick. They run on roughly the same lines as normal London transport trains (which use the same fare system as the subways). They just get there like 15 minutes faster on account of no stops. But the price difference is considerable, and lots of sales folks at the airport will try and talk you into wasting your money. If you’re just going into Central London and time isn’t crucial, you can get into Paddington Station (from Heathrow) or Victoria (from Gatwick) for like 1/4 of the same-day price. Just use CityMapper for more precise instructions, and ask a local (who isn’t power-walking) for guidance if need be. As is true everywhere, most people are very friendly and happy to help.(Oh, and I forgot to mention tipping. Not really necessary at bars or cafes unless you’re there for a longish time, and even then should be about the cost of one drink maybe. For sit-down restaurants 10% is pretty standard if they haven’t already added a “service fee” to your bill, which is basically a semi-forced tip often applied at fancier places or for large groups. For walking tours I would give the guide £5 or £10 depending how entertaining I found them and how much the tour was. Obviously good to tip more for volunteers. For families a £10 baseline is more appropriate, especially if your kids are slowing the group down at all or if the guide paid them special attention.)

Q. I am a medical student in Uganda. How can I get to practice medicine in Canada? Is it wise to redo medical school in Canada as a foreign medical graduate?A. Getting into a residency program in Canada as a Canadian graduate is getting harder. If you are able to, redoing medical school in Canada is the better choice. You would more likely be able to match into a specialty of your choice.All the best!Medical residency mismatch: number of unmatched Canadian medical graduates reaches all-time highCanada’s medical residency system is leaving some graduates in limbo | University AffairsThe International Student’s Guide to Landing a Medical Residency in CanadaMedical residency mismatch: number of unmatched Canadian medical graduates reaches all-time highThe number of Canadian medical graduates unmatched with a residency training program has reached unprecedented levels, with students and faculty concerned about the growing gap between students and necessary training.Since 2009, the number of unmatched Canadian graduates has been steadily increasing, moving from 11 in 2009 to 68 this year.“This represents 68 students who have spent on average eight to 10 years of undergraduate education to become physicians, incurring great debt, and utilizing taxpayer dollars to facilitate their education,” says Mel Lewis, a student affairs associate dean at the University of Alberta.“There’s a lot of anxiety,” says Franco Rizzuti, president of the Canadian Federation of Medical Students. “Students are starting to grasp at straws, trying to understand what’s going on.”A total of 64 training positions also went unmatched, including four in Alberta, two in Ontario and 58 in Quebec.To be able to practice medicine, all medical students need to complete a residency program in an area of specific clinical medicine, such as family medicine, surgery or psychiatry. Students compete with each other for a residency program through an application and matching process administered by the Canadian Resident Matching Service (CaRMS). This follows a very similar process to the one used in the United States.From a broader societal perspective, those who track health human resources nationally say there’s no reason to panic: 68 unmatched participants is a small fraction of the nearly 3,000 Canadian medical students who took part in this year’s match, and the 64 positions that remained unmatched typically end up filled.On an individual level, although being unmatched is stressful and a loss of a year, historically, virtually all unmatched students find success in subsequent years.Matching for a physician’s futureIn many ways, the Canadian medical residency match isn’t all that different from online dating: following a written application and interviews, students and training programs rank one another and an online algorithm is used to identify potential matches. In essence, both parties need to “swipe right” to make a match.However some training programs have fewer positions than applicants and other programs don’t have sufficient applicants of interest for their positions.There are two iterations of the match; the first is reserved for newly-graduated Canadian medical students. Students unmatched in the first round, as well as international medical graduates (including Canadian citizens studying in medical schools abroad) and Canadian medical graduates who went unmatched in previous years, join the second iteration.A student may choose to apply to only one program – training in cardiology at McGill or paediatrics at the University of British Columbia, for example – or rank multiple programs in multiple locations.Rizzuti says students apply to an average of 18 programs – nearly double the number of program applications compared to a decade ago. CaRMS data show there were 128,334 applications to 644 programs, up nearly five percent over last year.Historically, the match has had more wiggle room in the first round and a greater likelihood that Canadian medical graduates would match with their top-ranked training program.In 2009, the ratio of Canadian medical graduates versus residency positions was 1:1.12.“There was a little bit of a buffer in the system, a few more spots than there were Canadians applying. That gave some flexibility and allowed international medical graduates to come into the system,” says Genevieve Moineau, president & CEO of the Association of Faculties of Medicine of Canada.In 2017, the ratio shrank to 1:1.026. “Now instead of having a 10 percent buffer, you’ve got a 2.6 percent buffer. It’s really, really, really tight,” Moineau says.Mismatch in student interests versus training needsThe number and types of training positions available are usually decided by governments and medical schools, based on planning for population needs and medical school capacity. The exact process varies by jurisdiction, with population needs beginning to drive the process in some provinces.The overall number of residency positions available across Canada has remained largely unchanged since 2013, when it rose above 2,900. (Last year, the quota was 2,970. This year it was 2,967.)But the number of graduates participating in the match has outpaced growth in the quota. In 2013, there were 2,633 Canadian medical graduates participating. This year, that number rose to 2,810, a slight dip from 2016, when 2,836 medical graduates were looking for a match.“There has been a decline in residency spots, most notably in Ontario, with no commensurate decrease in medical student enrolment, squeezing the supply and demand quotient even further,” Lewis says.Exacerbating this tightened ratio is a long-standing mismatch between the personal career interests of medical students and where governments have funded training positions based on their view of future physician need.Some say it is an unreasonable expectation that every medical graduate should have the residency of their choice.“It’s, in part, the mindset,” says Ivy Lynn Bourgeault, who holds the Canadian Institutes of Health Research Chair in Gender, Work and Health Human Resources and is lead coordinator of the pan-Canadian Health Human Resources Network. “We should go where the need is. That should be inculcated in medical schools.”This year, graduates ranked dermatology, plastic surgery and emergency medicine highest, with demand for training in those disciplines far outstripping the supply of training spots.By contrast, after the first and second rounds of the match, opportunities in family medicine, psychiatry and laboratory sciences (which includes different types of pathology) were left unfilled.This year’s match also saw a slight reduction in the number of students prioritizing family medicine and more students ranking internal medicine, creating a wrinkle for students who could not have anticipated this shift and failed to give themselves options in their rankings.Applications from international medical graduates (IMGs) may also be a factor, putting more pressure on Canadian students looking to match in the second iteration. The number of IMGs participating in the match peaked at more than 3,100 in 2014, when the Objective Structured Clinical Examination became a mandatory requirement for all IMG applications outside of Saskatchewan. This year more than 2,400 IMGs participated.But Bourgeault argues that IMGs are not the problem, citing forthcoming research. “We under-utilize immigrants,” she says, noting that many of the IMGs who find success in the match process are willing to go where others won’t.Migration out of QuebecMigration within the country is also playing a role, with students in Quebec opting for residencies in other parts of the country. While bilingual students can rank positions in Anglophone Canada, English-speaking students can’t hope to place with a training position that requires French.This year’s match shows that while Quebec had 58 unfilled positions, it had only eight unmatched graduates, compared to 35 unmatched graduates from Ontario, 20 from Alberta and five from Atlantic Canada.“If students in Quebec are now taking positions outside of Quebec, and students who are hoping to match are not able to, there’s a disparity there,” Moineau says. “The tighter the ratio, the more variables of the playing field, the more challenging it becomes to match.”“Understanding why Quebec graduates don’t want these positions is key,” Bourgeault says.To deal with its perceived physician shortage, Quebec has introduced health care reforms, including actions focusing on physician workload, as well as regional medical resource plans that restrict where and how a physician can practice.A 2014 survey among Quebec medical residents found that 47 percent of those leaving medical residency for professional practice did not have a position two months before finishing their training. Among these residents without a position, 27 percent said they intended to leave Quebec. More than three-quarters of respondents said they believed there were not enough job opportunities for the number of trainees.Planning for the futureUnmatched Canadian graduates have two choices: they can opt to graduate and spend their time as they choose (perhaps doing a master’s program or research) until the match re-opens the following year, or they can defer graduation and instead take more electives as a medical student.Neither is ideal, Rizzuti says. “The former automatically puts you into debt repayment as you’re no longer a student. The latter, where they stay another year, means students are paying another full year of tuition. For Ontario, that’s $25,000 to $30,000.”“Solutions are complex,” Lewis says. “We need to have a better understanding of the types and number of physicians we need in Canada to help inform our students around their career planning and inform educators around curriculum planning. We need to ensure their are adequate residency spots available to our students with consideration of how many undergraduate medical students we should be graduating.”Moineau co-chairs a national physician resource planning committee that’s currently developing a tool to help forecast future physician needs, which will help make the case for changing student admissions or residency quotas to better align.“We feel strongly that we need to move to being in a society where we have the right number, mix and distribution to meet societal needs,” Moineau says.“This is where everybody needs to advocate to government that we need to have appropriate, long-term health human resource plans in place,” Rizzuti says. “There needs to be a broader conversation to be sure there’s proper alignment in all the steps in training.”Such a call is not new, dating back to at least the mid-1990s, with significant efforts undertaken to do such planning by governments, medical schools and medical associations.Students may also need more career counselling in the lead up to the match, Moineau says, as disciplines like surgery or laboratory sciences have become segmented, forcing students to choose a sub-specialty, like neurosurgery versus cardiac surgery, which may prove strategically disadvantageous.Health human resource planners may also need to take a closer look at how provincial funding and politics are influencing graduates’ choices about where to go for residency training.Training may also need to be revamped to ensure students get exposure to different disciplines, Rizzuti says, as many graduates are still turning away from rural and remote residencies, which could speak to their experience learning in mostly urban medical schools. The interest in family medicine as a first choice has also fluctuated markedly in the last 10 to 20 years.Opening more training spots for physicians is not the answer, Bourgeault says. In the health system as a whole, there are already a number of health care professionals whose skills are under-utilized, including nurse practitioners, pharmacists, physiotherapists and others.Instead, medical schools should be thinking about how to attract and prepare the students they need for the positions they’ve got, and continue to adjust the number and mix of residency spots to better meet societal need.“We need to do that better,” she says. “We have a distribution issue, we don’t necessarily have a numbers issues.”Canada’s medical residency system is leaving some graduates in limbo | University AffairsRobert Chu was a typical medical student in that he excelled at everything he did. He edited his high school newspaper and made it on the dean’s list in his undergraduate years. He volunteered to take notes for disabled students. After he got into medical school, he tutored hopefuls on the entry exam. “If somebody didn’t understand a concept, he was very good at explaining it to them in a manner that they could comprehend,” says his mother, Clara Chu. He was a skilled photographer and he loved to cook. Beef Wellington, macarons, homemade marshmallows. “Never anything simple,” his aunt, Cathy DeFazio, says with a laugh.In his final year of medical school, it surprised everyone that he didn’t get a residency training spot, the important last stage of training to become a physician. He gained more job shadowing experience and reapplied the next year to a less competitive specialty. When he was again refused a spot, Rob Whyte, assistant dean of undergraduate medical education at McMaster University, took the rare step of personally writing him a strongly worded recommendation letter. “Unlike some other students where we are able to readily identify a concern in their file, Robert presents no such evidence and we remain collectively frustrated at his situation,” he wrote.Robert, understandably, was the most frustrated of all, but he confronted the situation with the same resolve that had always worked for him. “He didn’t go halfway. It was all the way,” says Ms. DeFazio. He accessed and reviewed his reference letters – all glowing. He created flow charts of actions to take and people to contact. He wrote an impassioned letter explaining his plight and sent it to Prime Minister Justin Trudeau, then-Ontario Health Minister Eric Hoskins and others. There were a few sympathetic replies, but in the end, there was little anyone could do for him. He died by suicide in September 2016.Suicide can have many factors and eludes simple explanations. No one can presume what led Robert to his death, but the stress and frustration he felt must have been enormous. What’s more, the situation he experienced and was trying desperately to expose is happening to others: a growing number of medical school graduates are not getting a residency training position required to practice medicine in Canada. In other words, more and more students are completing four or five years of intensive, not to mention costly, medical school training – only to find they can’t proceed to the next stage.The residency application process is complicated, but to describe it simply, medical students apply – via the Canadian Resident Matching Service, or CaRMS – for residency positions at universities across the country in one or more specialties of their choice. The program committees select those they wish to interview, and then they rank the candidates. The medical school graduates in turn rank the programs, and an algorithm spits out a “match.” For those who don’t get matched, they can apply again over the next week for the remaining programs, often family medicine programs in small communities.In 2017, 68 final-year medical students went unmatched after the second round. Another 31 went unmatched in the first iteration but chose not to apply to the remaining programs, which likely didn’t include their specialties of choice. These numbers don’t include all the prior-year graduates who had failed to match in previous years and were trying again. By comparison, in 2005, only seven students who competed in the second round remained unmatched. If the trend continues, there will be an estimated 140 graduating students who go unmatched in 2021, and 330 if you include those who are re-applying for a second time, according to the Association of Faculties of Medicine of Canada (AFMC).In simple terms, more medical school graduates aren’t getting residency positions because the number of positions available has been decreasing in relation to the number of graduating medical students. “The most common reason a student doesn’t get matched is just musical chairs,” explains Anthony Sanfilippo, associate dean of undergraduate medical education in the faculty of health sciences at Queen’s University. A decade ago, there were about 114 residency positions for every 100 Canadian medical students, with internationally trained graduates filling the remaining positions. Today, there are 103 positions for every 100 Canadian medical school graduates.That may seem ideal, but many Quebec-based residency positions are available only to those who can speak French, and in 2017 more than 50 of these francophone positions remained unfilled. So there are actually fewer English-language positions than there are graduates, explains Kaylynn Purdy, vice-president of education for the Canadian Federation of Medical Students (CFMS). “It comes down to the fact that no matter how good you are, someone has to go unmatched,” she says.In this game of musical chairs, the stakes are high. For many, going unmatched is world-shattering. As Robert wrote in a letter sent to journalists and others, “My diligent studies of medical texts, careful practice of interview and examination skills with patients, and my student debt in excess of $100,000 on this pursuit have all been for naught.” For unmatched graduates, there’s the confusion about why they weren’t selected and the sudden uncertainty of the future. Students can apply when residency positions open up again the following year, but in the meantime, “you have resigned your fate to a year of being in limbo,” explains Aaron, a graduate who went unmatched in 2017 and asked to use a pseudonym. Feelings of social alienation often exacerbate the distress. “You go from being with this cohort of people for years and being quite close to them and they’re all celebrating and moving on with their lives and you’re not,” explains Ms. Purdy. “I’ve heard from some unmatched students that their classmates stopped talking to them because they didn’t want to make the person feel bad by talking about their residency, or the fact that they’re buying a house.” Clara Chu describes the phenomenon concisely: “Facebook,” she says, angrily.The crisis is worrying everyone – medical student organizations, the residency program directors and the undergraduate program administrators. “The deans have clearly identified the unmatched Canadian medical graduate as a top priority,” says Geneviève Moineau, president and CEO of AFMC. Ravi Sidhu, the postgraduate dean at the University of British Columbia’s medical school, says “the unmatched medical student numbers are incredibly disconcerting. I can imagine how stressful it is.”Who is going unmatched – and why – is difficult to grasp. Certainly, choosing a more competitive specialty can increase one’s risk of not getting a residency. In Robert’s first year of applying, he was one of 96 candidates vying for 81 radiology residencies. If family medicine had been his first choice, he would have almost certainly been matched – there were 200 more family medicine residencies than there were candidates who made the specialty their top choice. In 2017, obstetrics-gynecology was an especially competitive specialty, with 113 Canadian medical graduates vying for 77 residency spots. Paul Foster was one of the 36 ob-gyn hopefuls who didn’t match. His first reaction was self-doubt. “Maybe I screwed something up,” he thought, but then he heard of friends who suffered the same fate. “They’re superb candidates. It wasn’t the people with red flags,” he says.Some argue it’s students’ own fault for choosing very competitive specialties and not wanting to go where they’re needed – especially family medicine. But it’s difficult to know from one year to the next whether a specialty will be in demand. Provincial governments set the number of specialty training spots each year, based on changing population needs. And students’ preferences can swing considerably from year to year. Many years, for example, neurology has had a one-to-one ratio of applicants to spots; last year, there were positions for only 70 percent of applicants.Most of those who go unmatched are usually willing to do family medicine – more than two-thirds of graduates unmatched in the first round apply again in the second round to the remaining positions in family medicine and in small communities. But, here’s the clincher: the second round is also open to Canadians who have trained abroad. Last year, 1,811 internationally trained Canadians applied and 411 got positions. The directors of these programs often prefer a foreign-trained doctor whose first choice is family medicine, as opposed to a Canada-trained doctor who is choosing family medicine as a Plan B. As Dr. Moineau says, “family medicine can no longer be seen as a fallback.”Perhaps the most egregious aspect of the matching process is that those who go unmatched are discriminated against upon reapplying. In the one application review Robert Chu was able to obtain, his failure to match the year before was mentioned in the red-flag category. A decade ago, when only a handful of students didn’t get matched, there were often clear reasons, like a professionalism issue mentioned on their medical school record, for example. Today, even though many of those going unmatched are stellar students, the stereotype remains. While almost 97 percent of final-year students are matched, only 65 percent of prior-year grads get matched, despite the fact that most have improved their resumés with an extra year of job shadowing and research. With each additional application year, the chances of matching are lower.Illustration by Ka Young Lee.So what should be done? This past February, the AFMC, which represents Canada’s 17 faculties of medicine, released a list of recommendations to address the crisis of unmatched medical students. One of the most consequential suggestions is that international medical graduates no longer be allowed to apply for the positions that went unfilled in the first round, so that only graduates from Canadian medical schools can compete for these positions. (If this rule was in place last year, around 70 additional positions would have been earmarked for medical school graduates from Canada).It will be up to provincial governments to decide whether or not to adopt this recommendation. But provincial ministries of health are also getting pressure from internationally trained doctors and their families. They’re Canadians, too, and they’re lobbying for more opportunity to do postgraduate training here.Increasing the number of residency training spots would be one way to improve the prospects for budding Canadian-trained doctors. The AFMC is recommending that provincial funders work together to increase the minimum national ratio of one residency position for every current-year Canadian medical graduate. But that would cost money.Residency programs at universities, meanwhile, have been instructed to improve fairness and transparency in the application process. In October, the AFMC board approved a document of best practices in resident selection. For instance, programs should “explicitly and publicly state the processes and metrics they use to filter and rank candidates.” As well, a medical graduate’s previous unmatched status shouldn’t factor into a decision. Enforcing these best practices is difficult, however, because applicants aren’t told why they weren’t selected. In Robert’s case, he wrote emails to directors, asking for feedback. “Not knowing what the problem is makes it very difficult to address,” he explained. All programs refused to provide any insight.Kristina Arion, who went unmatched after applying for competitive ob-gyn residencies, likewise emailed program directors across Canada and was told, “Sorry, we provide no feedback.” Eventually, she got a single program director to review her file. He explained to her that candidates need all three referral letters to be exceptional. Though her letters were highly praiseful, one was written by an obstetrician who she worked with for less than a month; a letter from someone who had known her longer would have meant more. It was advice she found extremely helpful for this year’s application round.Dr. Sidhu at UBC explains that schools don’t provide feedback because it would be unwieldy. A competitive program might have to choose 50 candidates to interview out of 400 applicants, he points out. But most of those who aren’t selected for one program will be matched with another, and therefore won’t need advice. The CFMS has proposed that unmatched applicants should get unique access to timely feedback from residency programs.Undergraduate programs have a big role to play, too. Currently, some schools let unmatched students maintain their student status, so that they can access electives or job-shadowing positions. But other schools don’t offer an additional year. Doing electives can give students a leg up for the next year’s applications, which is why the CFMS is calling on all schools to extend student status to unmatched students. But paying a whole year of tuition isn’t great either, especially considering unmatched students are paying for electives only, not coursework. As it is, residency hopefuls are often paying to fly all over the country, first for electives and, secondly, for in-person interviews.“Despite the stereotype of the medical student with the silver spoon in their mouth, when you’re racking up interest on your debts, you’re going to start to see people who have maxed out their credit and are trying to judge, ‘Can I afford to go to this interview?’” says Dr. Foster, who is currently paying another $25,000 so that he can do electives at Western University.All undergraduate deans have agreed to begin “creating the structures” to support unmatched students, says Dr. Moineau, “including everything from extensive student affairs programs for unmatched students to creating the option for a fifth year.” The schools have agreed to report back to the AFMC by October with the changes they’ve implemented.For the Chu family, the changes are too late. His family still doesn’t understand why he didn’t get matched. As Dr. Whyte wrote, all of his clinical placement supervisors rated him “consistently above average or exceptional.” He was “extremely well motivated,” said one letter. “His clinical examination skills were excellent,” read another. In yet another letter, Robert’s interpersonal skills towards patients and staff was described as “outstanding.”“It’s not much consolation to be continually told I’ve done nothing wrong,” Robert wrote. Without a residency, the medical degree he had worked so hard to obtain had become, he felt, “effectively annulled.”Postscript: Just before University Affairs went to press, Kristina Arion and Paul Foster both learned that they were successfully matched to a residency in the first round of 2018, held on March 1. Dr. Foster was matched to the northern remote stream at the University of Manitoba and Dr. Arion to the ob-gyn residency program at Dalhousie University. General numbers on the success of the 2018 matching process were scheduled to be released sometime in April.Additional update: The numbers are now in for 2018. According to figures released on April 17 by the Canadian Resident Matching Service, there were 69 medical graduates who did not get a residency position this year after the second iteration of the residency matching process. Another 54 went unmatched in the first iteration who chose not to apply to the remaining programs. This compares to 68 and 31, respectively, in 2017. The two numbers combined, that’s a 24-percent increase in the number of unmatched medical graduates this year compared to last. These numbers don’t include prior-year graduates who tried again in 2018 to secure a residency but again did not get matched. This year, according to CaRMS, 57 of 133 prior-year graduates did get matched, a success rate of 57 percent.The International Student’s Guide to Landing a Medical Residency in Canada 04.30.2018Challenges can be scary, but you also think the greatest rewards are achieved by overcoming obstacles. You push yourself and it often leads to success.That doesn’t mean everything is always easy. You’ve encountered some challenges while applying to medical schools despite having a good academic record. You have started looking into international schools, but you may have heard that it could be difficult to secure a medical residency in Canada if you become an international medical graduate (IMG).As always, you’re up for the challenge. Just make sure you follow all of the necessary steps and prepare as fully as you can. Use this step-by-step guide to give yourself the best chance of securing a medical residency in Canada.THE PATH TO MEDICAL RESIDENCY IN CANADA1. MAKE SURE YOU MEET THE BASIC ELIGIBILITY REQUIREMENTSYou’ll need to meet a handful of eligibility requirements no matter which residency program you hope to attend. The basics include having Canadian citizenship or permanent resident status, successfully completing exam requirements, and demonstrating language proficiency. You’ll meet the language requirements if you attended a medical school where the language used for instruction was English or French. If you attended a program that was taught in another language, you’ll need to complete an assessment.Students who plan to begin residency in 2019 are the last class who need to complete the National Assessment Collaboration Examination (NAC) and the Medical Council of Canada Evaluating Examination (MCCEE) to meet basic eligibility requirements. November 2018 is the last MCCEE session.Going forward, IMGs will not be responsible for the above preliminary tests. Instead, you’ll need to proceed directly to completing the Medical Council of Canada Qualifying Examination (MCCQE) Part 1 before applying to residency programs. This mean future IMGs will enjoy a more streamlined process.Dr. Ivan Kamikovski, a St. George’s University grad and Orthopaedic Surgery Resident at the University of Ottawa, says strong exam scores have traditionally been very important for those who want to pursue family medicine.2. ADDRESS PROVINCE SPECIFICSYou really need to pay attention to the details when you start deciding where you want to attend residency, because different provinces have their own eligibility criteria. You may have to take additional steps to verify your medical degree, complete additional examinations, or enter into a service agreement that commits you to practicing in a particular area for a specific amount of time.Meeting certain provincial eligibility requirements can be extremely challenging, so you should take that into account when deciding where to apply. Manitoba, Saskatchewan, and Ontario are typically the friendliest toward IMGs, according to Dr. Alexander Hart, a Resident Physician in emergency medicine at the University of Toronto and IMG consultant for MD Consultants. “Within those provinces, there are a lot of universities,” he says.3. MAKE YOURSELF STAND OUTVery few people would argue IMGs have it easy when attempting to match for a medical residency in Canada, so anything you can do to boost your visibility would be wise. If possible, take advantage of opportunities near where you would like to practice. “I came to Canada for a period of time to do electives and got letters of reference from here,” Dr. Hart says.Dr. Kamikovski similarly pursued an elective in Canada, and he also made good use of his breaks during school. “When I came back to Canada, I would observe some of the orthopaedic surgeons,” he says, “Just to kind of get my name in there.”Building relationships with doctors and residents could be the key to securing a spot in a program later on. “In Canada, they’re more likely to take a person they know than a person who’s just on a list, a piece of paper,” Dr. Kamikovski says.Just remember that pursing an elective in Canada, while helpful, is not a requirement. There’s no guarantee of obtaining one of these positions since they’re offered through a lottery process.4. THINK CAREFULLY ABOUT YOUR SPECIALTY SELECTIONMedical students who complete their training in the US are required to obtain a Statement of Need, a form letter required for graduates who want to return to practice in Canada. Those who secure a residency in Canada can bypass this step in the process. But the List of Needed Specialties is still useful for seeing which fields offer a greater number of spots — typically primary care specialties. That said, some lucky IMGs have managed to secure competitive specialties.Dr. Kamikovski decided to go the specialty route. He says there are fewer job opportunities in orthopaedic surgery, so he felt many applicants were choosing family medicine and other primary care positions. Just know instructors and other IMGs think this is a risky move.It’s also important to note that, at least for most provinces, residency programs evaluate you separately from Canadian medical graduates."You’re typically competing only against other IMGs. But the spots are more restricted."“You’re typically competing only against other IMGs,” Dr. Hart says. “But the spots are more restricted.” If you attended a quality international program, performed well on your exam, and obtained strong letters of recommendation, you stand a better chance.5. APPLY TO PROGRAMS AND ATTEND INTERVIEWSYou’ll apply for residency positions using the Canadian Resident Matching Service (CaRMS). “It’s one central application system and that sends out your application to multiple schools,” Dr. Kamikovski explains."It’s one central application system and that sends out your application to multiple schools."Though you can start selecting programs before you’ve gathered all of your materials, it’s important to note that everything must be completed by a specific date in November to be considered on time. The CaRMS has a timeline you may find useful for staying on track.After programs have a chance to evaluate applications, they’ll begin to host interviews during January and February. As with medical school interviews, preparation is key. Take advantage of any mock interviews your medical school offers and make sure you do your research on individual programs.6. RANK PROGRAMS, THEN WAIT FOR YOUR RESULTSThe CaRMS uses the same algorithm the National Resident Matching Program (NRMP) relies on to match applicants to programs. You can’t outsmart the system, so you will want to create a rank order list based on your true preferences. Your interviews should have provided you with most of the information you need to rank your selections.If you start second-guessing your choices, you may want to consult with a trusted mentor. It’s also smart to remind yourself of what it is you’re looking for in a program. For example, Dr. Hart says the University of Toronto is a good option for those who are interested in a niche area of medicine. “That’s the kind of thing that Toronto, above all else, really provides,” he explains. Even still, you don’t want to become too aspirational."That’s the kind of thing that Toronto, above all else, really provides."After you submit your rank order list, you may feel a bit anxious. It’s true that matching is difficult, but it’s not impossible. According to the Canadian Post-MD Education Registry (CAPER), hundreds of IMGs begin Canadian post-graduate medical training every year.TAKE THE NEXT STEPObtaining a medical residency in Canada requires some additional steps, hard work, and a certain amount of luck. But it’s not an impossible task. A residency in Canada could be in your future.Also keep in mind that it’s possible to practice medicine in Canada after completing residency training in the US. While there are a few extra steps, this is a feasible path for IMGs.If you have started looking into programs in the Caribbean as an option, you’ll want to make sure you do your research. But it can be a little tricky to know what you should believe. Make sure you’re distinguishing fact from fiction by reading our article, “The Truth About Caribbean Medical Schools: Debunking the Myths.”

This is the max they can do to scrutinize the physical testing.Its for Pilots. Leniency is expected in case of ground guty.GENERAL MEDICAL AND SURGICAL ASSESSMENT1.2.1. Every candidate, to be fit for the Air Force, must conform to the minimum standards laid down in the succeeding paragraphs. The general build should be well developed and proportionate.Surgical Sequelae and Abnormalities1.2.2. Sequelae of Fractures/ Old injuries. The residual effects of such fractures/ injuries are to be assessed for any functional limitation. If there is no effect on function, the candidate can be assessed fit. Cases of old fractures of spine are unfit. Any residual deformity of spine or compression of a vertebra will be cause for rejection. Injuries involving the trunks of the larger nerves, resulting in loss of function, or scarring, which cause pain or cramps, indicate unsuitability for employment in flying duties. The presence of large or multiple keloids will be cause for rejection.1.2.3. Scars and Birth Marks. Minor scars for e.g. as resulting from the removal of tuberculous glands do not, per se, indicate unsuitability for employment on flying duties. Extensive scarring of a limb or torso that may cause functional limitation or unsightly appearance should be considered unfit.1.2.4. Cervical Rib. A well fully developed unilateral cervical rib or a rudimentary large cervical rib with signs or symptoms referable to the rib is a cause for rejection. Rudimentary small cervical rib without signs or symptoms referable to it may be considered fit. However, the defect is to be recorded as a minor disability in the medical board proceedings. Bilateral cervical ribs without any neurovascular compromise will be acceptable.1.2.5. Asymmetry of the face and head, which will interfere with proper fitting of oxygen mask and helmet, will be a cause for rejection for flying duties.1.2.6. History relating to operations. A candidate who has undergone an abdominal operation, other than a simple appendicectomy, involving extensive surgical intervention or partial or total excision of any organ is, as a rule, unsuitable for flying duties. Operation involving the cranial vault (e.g.trephining), or extensive thoracic operations such as thoracoplasty make the candidate unfit for flying.Measurement and Physique1.2.7. Chest shape and circumference. The shape of the chest is as important as its actual measurement. The chest should be well proportioned and well developed with the minimum range of expansion of 5 cm. Decimal fraction lower than 0.5 cm will be ignored. 0.5 cm will be recorded as such and 0.6 cm and above will be recorded as 1 cm.1.2.8. Height, Sitting Height, Leg Length and Thigh Length. The minimum height for entry into ground duty branches will be 157.5 cm.1.2.9. Minimum height for Flying Branch Acceptable measurements of leg length, thigh length and sitting height for such aircrew will be as under: -(a) Sitting height - Minimum 81.50 cm- Maximum 96 .0 cm(b) Leg Length - Minimum 99.0 cm- Maximum 120.0 cm(c) Thigh Length - Maximum 64.0 cm1.2.10. On account of lower age group of NDA candidates a margin of up to 5.0 cm in height, 2.5 cm in leg length (minimum) and 1.0 cm in sitting height (minimum) may be given provided it is certified by the medical board that the candidate is likely to grow and come up to the required standard on completion of his training at NDA. The actual growth is to be confirmed at the time of V term medical at NDA.1.2.11. Weight(a) Male Candidates (except NDA candidates). Ideal weight relative to age and height is as depicted in Appendix A to this chapter. For male candidates (except NDA candidates), the maximum permissible variation from the ideal body weight is ± 1SD. Fraction of less than half a Kg will not be noted.(b) NDA Candidates. For NDA candidates, at entry, the weight chart prescribed by U.P.S.C. placed at Appendix B to this chapter will be applicable. placed at Appendix B to this chapter will be applicable. Fraction of less than half a Kg will not be noted. If a candidate is overweight by more than 10 % of the ideal weight, biochemical parameters will be assessed to rule out any underlying pathology. Candidates with weight between 10 to 20 % of ideal with normal biochemical profile, normal waist circumference (< 94 cm:Males and 89 cm: Females), normal BMI range (M< 25, F< 23) and normal waist to hip ratio (< 0.9: Males and <0.8: Females) may be assessed fit. It must be ensured that all the four obesity parameters mentioned before are normal. Abnormality in any one of them will be a cause for rejection. Genetic factors must also be considered in young age obesity. Skin fold thickness and measurement of body fat with body fat analyzers, where available, may be done. Such candidates, if found fit, would be advised to reduce weight to less than 10% of ideal which should be ensured by the time the candidate joins NDA and subsequently, AFA (this stipulation is also endorsed in the joining instructions of the candidate). Candidates with weight more than 20 % above the ideal, with or without biochemical abnormalities, or BMI more than 25 or waist circumference more than 94cm, or WHR > 0.9 will be declared unfit. If a candidate is underweight by more than 10% below the ideal, a detailed history and careful examination to rule out possible causes like tuberculosis, hyperthyroidism, diabetes etc will be carried out. If no cause is detected the candidate will be declared fit. If any cause is detected the fitness of the candidate will be decided accordingly.1.2.12. Physical Standards (For Females).(a) Height. The minimum height acceptable for various branches are as follows:-(i) Flying Branch - 162.5 cm.(ii) Medical / Dental branches – 142 cm(iii) Other Branches – 152 cmNote: For other than flying branches only – For candidates belonging to the North East region or hilly regions of Uttaranchal, a lower minimum height of 142 cm will be accepted.CARDIOVASCULAR SYSTEM1.3.1. Relevant history. History of chest pain, breathlessness, palpitation, fainting attacks, giddiness, rheumatic fever, chorea, frequent sore throats and tonsillitis should be given due consideration in assessment of the cardiovascular system.1.3.2. Pulse. The normal pulse rate varies from 60-100 bpm. Persistent sinus tachycardia (> 100 bpm), after emotional factors and fever are excluded as causes, as well as, persistent sinus bradycardia (< 60 bpm), should be referred for specialist opinion to exclude organic causes. Sinus arrhythmia and vagotonia should be also be excluded.1.3.3. Candidates are quite prone to develop White Coat Hypertension, which is a transient rise of Blood Pressure, due to the stress of medical examination. Every effort must be made to eliminate the White Coat effect by repeated recordings under basal conditions. When indicated, ambulatory BP recording must be carried out or the candidate admitted to hospital for observation before final fitness is certified. An individual with BP consistently greater than 140/90 mm Hg shall be rejected.1.3.4. Evidence of organic cardio vascular disease will be cause for rejection. Diastolic murmurs are invariably organic. Short systolic murmurs of ejection systolic nature and not associated with thrill and which diminish on standing, specially if associated with a normal ECG and Chest X-Ray, are most often functional. However an echocardiogram should always be done to exclude organic heart disease. In case of any doubt the case should be referred to cardiologist for opinion.1.3.5. Electro Cardiograms. Assessment of a properly recorded ECG (resting – 14 lead) should be carried out by a medical specialist. Note will be taken of wave patterns, the amplitude, duration and time relationship. At initial entry no abnormalities are acceptable except incomplete RBBB in the absence of structural heart disease, which must be excluded. In such cases, opinion of Senior Adviser or Cardiologist will be obtained.CHAPTER 4RESPIRATORY SYSTEM1.4.1. Pulmonary TB. Any residual scarring in pulmonary parenchyma or pleura, as evidenced by a demonstrable opacity on chest skiagram will be a ground for rejection.1.4.2. Pleurisy with Effusion. Any evidence of significant residual pleural thickening will be a cause for rejection. Old treated cases with no residual abnormality can be accepted if the diagnosis and treatment was completed more than two year earlier. In these cases, a CT scan chest and fibro optic bronchoscopy with bronchial lavage can be done alongwith USG, ESR, and Mantoux test. If all the tests are normal the candidate may be considered fit.1.4.3. Bronchitis. History of repeated attacks of cough/ wheezing/ bronchitis may be manifestations of chronic bronchitis or other chronic pathology of the respiratory tract. Such cases will be assessed unfit.1.4.4.Bronchial Asthma. History of repeated attacks of bronchial asthma/wheezing/ allergic rhinitis will be a cause for rejection.1.4.5. Radiographs of the chest. Definite radiological evidence of disease of the lungs, mediastinum and pleurae indicates unsuitability for employment in air force.CHAPTER 5GASTRO INTESTINAL SYSTEM1.5.1. Relevant History. The examiner should enquire whether the candidate has any past history of ulceration or infection of the mouth, tongue, gums or throat. Record should be made of any major dental alteration.1.5.2. When discussing a candidate’s medical history the examiner must ask direct questions about any history of heart burn, history of recurrent dyspepsia, peptic ulcer-type pain, persistent diarrhoea, jaundice or biliary colic.1.5.3. Dental Standards. The following dental standard will be followed:-(a) Candidate must have 14 dental points and the following teeth must be present in the upper jaw in good functional opposition with the corresponding teeth in the lower jaw, and these must be sound or repairable:-(i) Any four of the six anteriors, and(ii) Any six of the ten posteriors(iii) They should be balancing on both sides. Unilateral masticationis not allowed.(iv) Any removable or wired prosthesis are not permitted.(b) Candidate whose dental standard does not conform to the laid down standard will be rejected.(c) Candidate with dental arches affected by advanced stage of generalized active lesions of pyorrhoea, acute ulcerative gingivitis, and gross abnormality of the teeth or jaws or with numerous caries or septic teeth will be rejected.1.5.4 Gastro-Duodenal disabilities. Candidates who are suffering or have suffered, during the previous two years, from symptoms suggestive of chronic indigestion, including proven peptic ulceration, are not to be accepted, in view of the exceedingly high risk of recurrence of symptoms and potential for incapacitation. Any past surgical procedure involving partial or total loss of an organ (other than vestigial organs/ gall bladder) will entail rejection.1.5.5 Diseases of the Liver. If past history of jaundice is noted or any abnormality of the liver function is suspected, full investigation is required for assessment. Candidates suffering from viral hepatitis or any other form of jaundice will be rejected. Such candidates can be declared fit after a minimum period of 6 months has elapsed provided there is full clinical recovery; HBV and HCV status are both negative and liver functions are within normal limits.1.5.6 Disease of spleen. Candidates, who have undergone splenectomy, are unfit, irrespective of the cause for operation. Splenomegaly of any degree is a cause for rejection.1.5.7. Hernia. A candidate with a well-healed hernia scar, after successful surgery, will be considered fit six months after surgery, provided there is no potential for any recurrence and abdominal musculature is good.1.5.8. Abdominal Surgery.(a) A candidate with well-healed scar after conventional abdominal surgery will be considered fit after 6 months of successful surgery provided there is no potential for any recurrence of the underlying pathology and abdominal wall musculature is good.(b) A candidate after laparoscopic cholecystectomy will be considered fit three months after successful surgery.1.5.9. USG Abdomen: Disposal of cases with incidental ultrasonographic findings like fatty liver, small cysts, haemangiomas, septate gall bladder etc., will be based on clinical significance and functional capacity.CHAPTER 6UROGENITAL SYSTEM1.6.1. Relevant History. Enquiry should be made about any alteration in micturition, e.g. dysuria or frequency. Recurrent attacks of cystitis; pyelonephritis and haematuria must be excluded. Detailed enquiry must be made about any history of renal colic, attacks of acute nephritis, any operation on the renal tract including loss of a kidney, passing of stones or urethral discharges. If there is any history of enuresis, past or present, full details must be obtained.1.6.2. Urine Examination.(a) Proteinuria. Proteinuria will be a cause for rejection, unless it proves to be orthostatic.(b) Glycosuria. When glycosuria is detected, a blood sugar examination (Fasting and after 75 g glucose) and Glycosylated Hb is to be carried out, and fitness decided as per results. Renal glycosuria is not a cause for rejection.(c) Urinary Infections. When the candidate has history or evidence of urinary infection it will entail full renal investigation. Persistent evidence of urinary infection will entail rejection.(d) Haematuria. Candidates with history of haematuria will be subjected to full renal investigation.1.6.3. Glomerulonephritis.(a) Acute. In this condition there is a high rate of recovery in the acute phase, particularly in childhood. A candidate who has made a complete recovery and has no proteinuria may be assessed fit, after a minimum period of one year after full recovery.(b) Chronic. Candidate with chronic glomerulonephritis will be rejected.1.6.4. Renal Colic and Renal Calculi. Complete renal evaluation is required. Candidates with renal calculi will be rejected.1.6.5. Absence of Kidney. All candidates found to have congenital absence of one kidney or who have undergone unilateral nephrectomy will be rejected. Presence of horseshoe kidney will entail rejection. Solitary functioning kidney with diseased, non-functional contralateral kidney will entail rejection. Crossed ectopia, unascended kidney(s) will be a cause for rejection.1.6.6. Undescended Testis. Bilateral undescended testis / atrophied testis will be a cause for rejection. Unilateral undescended testis, if entirely retained in the abdomen, is acceptable. If it lies in the inguinal canal, at the external ring or in the abdominal wall, such cases may be accepted after either orchiectomy or orchipexy operation. In all doubtful cases surgical opinion must be obtained regarding fitness.1.6.7. Hydrocele or Varicocele. These should be properly treated before fitness is considered. Minor degree of varicocele should not entail rejection.CHAPTER 7ENDOCRINE SYSTEM1.7.1. Generally any history suggestive of endocrine disorders will be a cause for rejection.1.7.2. All cases of thyroid swelling having abnormal iodine uptake and abnormal thyroid hormone levels will be rejected. Cases of simple goiter with minimal thyroid swelling, who are clinically euthyroid and have normal iodine uptake and normal thyroid functions may be accepted.1.7.3. Candidates detected to have diabetes mellitus will be rejected. A candidate with a family history of diabetes mellitus will be subjected to blood sugar and Glycosylated Hb evaluation, which will be recorded.CHAPTER 8DERMATOLOGICAL SYSTEM1.8.1. Relevant history and examination. Careful interrogation followed by examination of the candidates skin is necessary to obtain a clear picture of the nature and severity of any dermatological condition claimed or found. Borderline skin conditions should be referred to a dermatologist. Candidates who give history of sexual exposure, or have evidence of healed penile sore in the form of a scar should be declared permanently unfit, even in absence of an overt STD, as these candidates are likely ‘repeaters’ with similar indulgent promiscuous behavior.1.8.2. Assessment of diseases of the Skin. Acute non-exanthematous and noncommunicable diseases, which ordinarily run a temporary course, need not be a cause of rejection. Diseases of a trivial nature, and those, which do not interfere with general health or cause incapacity, do not entail rejection.1.8.3. Certain skin conditions are apt to become active and incapacitating under tropical conditions. An individual is unsuitable for service if he has a definite history or signs of chronic or recurrent skin diseases. Some such conditions are described below:-(a) Palmoplantar Hyperhydrosis. Some amount of Palmoplantar Hyperhydrosis is physiological, considering the situation that recruits face during medical examination. However, conditions with significant Palmoplantar Hyperhydrosis should be considered unfit.(b) Acne Vulgaris. Mild (Grade 1) Acne consisting of few comedones or papules, localized only to the face may be acceptable. However moderate to severe degree of acne (nodulocystic type with or without keloidal scarring) or involving the back should be considered unfit.(c) Palmoplantar Keratoderma. Any degree of palmoplantar keratoderma manifesting with hyperkeratotic and fissured skin over the palms, soles and heels should be considered unfit.(d) Ichthyosis Vulgaris. Ichthyosis involving the upper and lower limbs, with evident dry, scaly, fissured skin should be considered unfit. Mild Xerosis (dry skin) could be considered fit.(e) Keloids. Candidates having any keloid should be considered unfit.(f) Onychomycosis. Clinically evident onychomycosis of finger and toenails should be declared unfit, especially if associated with nail dystrophy. Mild degree of distal discolouration involving single nail without any dystrophy may be acceptable.(g) Giant Congenital Melanocytic Naevus. Giant congenital melanocytic naevi, greater than 10 cm should be considered unfit, as there is a malignant potential in such large sized naevi.(h) Callosities, corns and warts. Small sized callosities, corns and warts may be considered acceptable after treatment. However candidates with multiple common warts or diffuse palmoplantar mosaic warts, large callosities on pressure areas of palms and soles and multiple corns should be rejected.(j) Psoriasis. Psoriasis is a chronic skin condition known to relapse and/or recur and hence should be considered unfit.(k) Leukoderma. Candidates suffering from minor degree of Leukoderma affecting the covered parts may be accepted. Vitiligo limited only to glans and prepuce maybe considered fit. But those having extensive degree of skin involvement and especially, when the exposed parts are affected, even to a minor degree, should not be accepted.1.8.4. A history of chronic or recurrent attacks of skin infections will be cause for rejection. A simple attack of boils or sycosis from which there has been complete recovery may be considered for acceptance.1.8.5. Individuals who have chronic or frequently recurring attacks of a skin disease of a serious or incapacitating nature e.g. eczema are to be assessed as permanently unfit and rejected.1.8.6. Any sign of Leprosy will be a cause for rejection.1.8.7. Naevi. Naevus depigmentosus, Beckers Naevus may be considered it. Intradermal Naevus, Vascular Naevi may be considered unfit.1.8.8. Ptyriasis Versicolor. Mild P Versicolor may be considered fit. Extensive Ptyriasis Versicolor may be considered unfit.1.8.9. Tinea Cruris and Tinea Corporis. Maybe considered fit on recovery.1.8.10. Scrotal Eczema. Maybe considered fit on recovery.1.8.11 Canities (premature graying stain) maybe considered fit if mild in nature and no systemic association is seen.1.8.12. Intertrigo. Maybe considered fit on recovery.1.8.13. Sexually Transmitted Diseases : Genital Ulcers. These should be considered unfit.1.8.14. Scabies. Maybe considered fit only on recovery. Genital scabies maybe made unfit.CHAPTER 9MUSCULOSKELETAL SYSTEM AND PHYSICAL CAPACITYPhysical Endurance1.9.1. The assessment of the candidate’s physique is to be based upon careful observation of such general parameters as apparent muscular development, age, height, weight and the correlation of this i.e. potential ability to acquire physical stamina with training. The candidate’s physical capacity is affected by general physical development or by any constitutional or pathological condition.Spinal Conditions1.9.2. Relevant history. Past medical history of disease or injury of the spine or sacroiliac joints, either with or without objective signs, which has prevented the candidate from successfully following a physically active life, is a cause for rejection for commissioning. History of spinal fracture/ prolapsed intervertebral disc and surgical treatment for these conditions will entail rejection.1.9.3. Examination. Mild kyphosis or lordosis where deformity is barely noticeable and not associated with pain or restriction of movement may be accepted. When scoliosis is noticeable or any pathological condition of the spine is suspected, X-ray examination of the appropriate part of the spine needs to be carried out.1.9.4. X-Ray Spine. For flying duties, X-ray (AP and lateral views) of cervical, thoracic and lumbosacral spines is to be carried out. For ground duties, X-ray examination of spine may be carried out, if deemed necessary.1.9.5. Assessment. The following conditions detected radiologically will disqualify a candidate for Air Force service: -(a) Granulomatous disease of spine.(b) Arthritis / Spondylosis.(i) Rheumatoid arthritis and allied disorders.(ii) Ankylosing Spondylitis.(iii) Osteoarthrosis, spondylosis and degenerative joint disease.(iv) Non-articular rheumatism (e.g. lesions of the rotator cuff, tennis elbow, recurrent lumbago etc.)(v) Misc disorders including SLE, ,Polymyositis, and Vasculitis.(vi) Spondylolisthesis / spondylolysis(vii) Compression fracture of Vertebra(viii) Scheuerman’s Disease (Adolescent Kyphosis)(ix) Loss of cervical lordosis when associated with clinically restricted movements of cervical spine.(x) Unilateral / Bilateral Cervical ribs with demonstrable neurological or circulatory deficit.(xi) Any other abnormality is so considered by the specialist.1.9.6. Fitness for Flying Duties. The deformities/disease contained in para 1.9.5 above will be cause of rejection for all branches in IAF. In addition for candidates for flying branches the under mentioned rules will also apply: -(a) Spinal anomalies acceptable for flying duties: -(i) Bilateral complete sacralisation of LV5 and bilateral complete lumbarisation of SV1.(ii) Spine bifida in sacrum and in LV5, if completely sacralised.(iii) Complete block (fused) vertebrae in cervical and /or dorsal spine at a single level.Note: However, an annotation will be made of these anomalies in AFMSF-2.(b) Spinal conditions not acceptable for flying duties.(i) Scoliosis more than 15 degree as measured by Cobb’s method.(ii) Degenerative disc disease.(iii) Presence of Schmorl’s nodes at more than one level.(iv) Atlanto - occipital and atlanto-axial anomalies.(v) Hemi vertebra and/or incomplete block (fused) vertebra at any level in cervical, dorsal or lumbar spine and complete block (fused) vertebra at more than one level in cervical or dorsal spine.(vi) Unilateral sacralisation or lumbarisation (complete or incomplete) at all levels and bilateral incomplete sacralisation or lumbarisation.Conditions affecting the assessment of Upper Limbs1.9.7. Amputations. Candidate with an amputation of an upper limb will not be accepted for entry. Amputation of terminal phalanx of little finger on both sides is, however, acceptable1.9.8. Fingers and Hands. Deformities of the upper limbs or their parts will be cause for rejection. Syndactyly, polydactyly will be assessed as unfit except when polydactyly is excised.1.9.9. Wrist. Painless limitation movement of wrist will be graded according to the degree of stiffness. Loss of dorsiflexion is more serious than loss of palmer flexion.1.9.10. Elbow. Slight limitation of movement does not bar acceptance provided functional capacity is adequate. Ankylosis will entail rejection. Carrying angle of more than 15 degree for male and more 18 degree for female candidates will be a cause for rejection.1.9.11. Shoulder Girdle. History of recurrent dislocation of shoulder will entail rejection.1.9.12. Clavicle. Malunion / non-union of an old fracture clavicle will entail rejection.Conditions affecting the assessment of Lower Limbs1.9.13. Hallux Valgus. Mild cases (less than 20 degrees), asymptomatic, without any associated corn / callosities / bunion, are acceptable. Other cases will entail rejection. Shortening of first metatarsal is also considered unfit.1.9.14. Hallux rigidus. Hallux rigidus is not acceptable.1.9.15. Hammer Toes (single or multiple). Isolated single flexible mild hammertoe with no history of disabling symptoms may be accepted. Fixed (rigid) deformity or hammertoe associated with corns, callosities, mallet toes or hyperextension at metatarsophalangeal joint (claw toe deformity) is causes for rejection.1.9.16. Loss of Digits. Loss of any digit of the toes or fingers entails rejection.1.9.17. Extra Digits. Extra digits will entail rejection if there is bony continuity with adjacent digits. Cases of syndactly or loss of toes/fingers will be rejected.1.9.18. Flat feet. Feet may look apparent flat. If the arches of the feet reappear on standing on toes, if the candidate can skip and run well on the toes and if the feet are supple, mobile and painless, the candidate is acceptable. Restriction of the movements of the foot will also be a cause for rejection. Rigidity of the foot, whatever may be the shape of the foot, is a cause for rejection.1.9.19. Pes Cavus and Talipes (Club Foot). Mild degree of idiopathic pes cavus is acceptable. Moderate and severe pes cavus and pes cavus due to organic disease will entail rejection. All cases of Talipes (Club Foot) will be rejected.1.9.20. The Ankle Joints. Any significant limitation of movement following previous injuries will not be accepted. However, cases with no history of recurrent trouble and having plantar and dorsiflexion movement of at least 20 degree may be assessed fit for ground duties. Fitness for aircrew duties will be based on functional evaluation.1.9.21. The Knee Joint. History or clinical signs suggestive of Internal Derangement of Knee will need careful consideration. Fitness in such cases will be based on functional evaluation and possibility/progression/recurrance of the treated pathology.1.9.22. Genu Valgum (Knock Knee). If the distance between the internal malleoli is less than 5 cm, without any other deformity, the candidate is considered fit. If the distance between the two internal malleoli is more than 5 cm, he should be declared unfit.1.9.23. Genu Varum (Bow Legs). If the distance between the femoral condyles is within 10 cm the candidate should be considered fit.1.9.24. Genu Recurvatum. If the hyperextension of the knee is within 10 degrees and is unaccompanied by any other deformity, the candidate should be accepted as fit.1.9.25. Hip Joint. True lesions of the hip joint will entail rejection.CHAPTER 10CENTRAL NERVOUS SYSTEMRelevant Personal History1.10.1. Mental Illness. A candidate giving a history of mental illness/psychological afflictions requires detailed investigation and psychiatric referral. Such cases should normally be rejected. Most often the history is not volunteered. The examiner should try to elicit a history by direct questioning, which may or may not be fruitful. Every examiner should form a general impression of the candidate’s personality as a whole and may enquire into an individual’s stability and habitual reactions to difficult and stressful situations.1.10.2. Insomnia, Nightmare, Sleepwalking or bed-wetting. History of insomnia, nightmares or frequent sleepwalking, when recurrent or persistent, will be a cause for rejection.1.10.3 Severe or ‘throbbing’ Headache and Migraine. Common types of recurrent headaches are those due to former head injury or migraine. Other forms of occasional headache must be considered in relation to their probable cause. A candidate with migraine, which was severe enough to make him consult his doctor, should normally be a cause for rejection. Even a single attack of migraine with visual disturbance or ‘Migrainous epilepsy’ is a bar to acceptance.1.10.4. Fits and convulsions. History of epilepsy in a candidate is a cause for rejection. Convulsions/fits after the age of five are also a cause for rejection. Convulsions in infancy may not be of ominous nature provided it appears that the convulsions were febrile convulsions and were not associated with any overt neurological deficit. Causes of epilepsy include genetic factors, traumatic brain injury, stroke, infection, demyelinating and degenerative disorders, birth defects, substance abuse and withdrawal seizures. Enquiry should not be limited only to the occurrence of major attacks. Complex Partial seizures may masquerade as “faints” and therefore the frequency and the conditions under which “faints” took place must be elicited. Such attacks indicate unsuitability for flying, whatever their apparent nature. An isolated fainting attack calls for enquiry into all the attendant factors to distinguish between syncope and seizures. For e.g. fainting in school is of common occurrence and may have little significance. Other complex partial seizures may manifest as vegetative movements as lip smacking, chewing, staring, dazed appearance and periods of unresponsiveness. In any event, a prolonged period of freedom from recurrence must have elapsed before fitness for flying duties can be considered and if the electroencephalogram does not show any specific abnormality.1.10.5. Heat stroke. History of repeated attacks of heat stroke, hyperpyrexia or heat exhaustion bars employment for air force duties, as it is an evidence of a faulty heat regulating mechanism. A single severe attack of heat effects, provided the history of exposure was severe, and no permanent sequelae were evident is, by itself, not a reason for rejecting the candidate.1.10.6. Head Injury or Concussion. A history of severe head injury is a cause for rejection. The degree of severity may be gauged from the history of duration of Post Traumatic Amnesia (PTA). Mild brain injury is associated with 0-1 hour PTA, moderate with 1 – 24 hours PTA, severe with 1-7 days PTA and very severe with > 7 days of PTA. Other sequalae of head injury are post concussion syndrome which has subjective symptoms of headache, giddiness, insomnia, restlessness, irritability, poor concentration and attention deficits; focal neurological deficit, posttraumatic epilepsy and posttraumatic neuropsychological impairment which includes deficits in attention concentration, information processing speeds, mental flexibility and frontal lobe executive functions and psychosocial functioning. Neuropsychological testing including pyschometry can assess these aspects. It is important to realize that sequelae may persist for considerable period and may even be permanent. Fracture of the skull need not be a cause for rejection unless there is a history of associated intracranial damage or of depressed fracture or loss of bone. When there is a history of severe injury or an associated convulsive attack, an electroencephalogram should be carried out which must be normal. Presence of burr holes will be cause for rejection for flying duties, but not for ground duties. Each case is to be judged on individual merits. Opinion of neurosurgeon and psychiatrist must be obtained before acceptance.Family History1.10.7. History of Psychological Disorders. When a history of nervous break down, mental disease, of suicide of a near relative is obtained, a careful investigation of the personal past history from a psychological point of view is to be obtained. While such a history per se is not a bar to air force duties any evidence of even the slightest psychological instability, in the personal history or present condition, should entail rejection.1.10.8. Epilepsy. If a family history of epilepsy is admitted an attempt should be made to determine its type. When the condition has occurred in a near (first degree) relative, the candidate may be accepted, if he has no history of associated disturbance of consciousness, neurological deficit or higher mental functions and his electroencephalogram is completely normal.1.10.9. Emotional Stability. The assessment of emotional stability the must include family and personal history, any indication of emotional liability under stress as evidenced by the occurrence of undue emotionalism as a child or of any previous nervous illness or breakdown. The presence of stammering, tic, nail biting, excessive hyperhydrosis or restlessness during examination could be indicative of emotional instability.1.10.10. Psychosis. All candidates who are suffering from psychosis are to be rejected. Drug dependence in any form will also be a cause for rejection.1.10.11. Psychoneurosis. Mentally unstable and neurotic individuals are unfit for commissioning. Juvenile and adult delinquency, history of nervous breakdown or chronic ill health are causes for rejection. Particular attention should be paid to such factors as unhappy childhood, poor family background, truancy, juvenile and adult delinquency, poor employment and social maladjustment records, history of nervous break down or chronic ill-health, particularly if these have interfered with employment in the past.1.10.12. Organic Nervous Conditions. Any evident neurological deficit should call for rejection.1.10.13. Tremors. Tremors are rhythmic oscillatory movements of reciprocally innervated muscle groups. Two categories are recognized: normal or physiologic and abnormal or pathologic. Fine tremor is present in all contracting muscle groups, it persists throughout the waking state, the movement is fine between 8 to 13 Hz. Pathologic tremor is coarse, between 4 to 7 Hz and usually affects the distal part of limbs. Gross tremors are generally due to enhanced physiological causes where, at the same frequency, the amplitude of the tremor is grossly enhanced and is elicited by outstretching the arms and fingers which are spread apart. This occurs in cases of excessive fright, anger, anxiety, intense physical exertion, metabolic disturbances including hyperthyroidism, alcohol withdrawal and toxic effects of lithium, smoking (nicotine) and excessive tea, coffee. Other causes of coarse tremor are parkinsonism, cerebellar (intention) tremor, essential (familial) tremor, tremors of neuropathy and postural or action tremors.1.10.14. Stammering. Candidates with stammering will not be accepted for air force duties. Careful assessment by ENT Specialist, Speech therapist, psychologist/ psychiatrist may be required.1.10.15. Basal E.E.G. Only those candidates for aircrew duties will be subjected to EEG examination as specified in para 2.9.13. Those with following EEG abnormalities in resting EEG or EEG under provocative techniques will be rejected for aircrew duties: -(a) Background Activity. Focal, excessive and high amplitude beta activity /hemispherical asymmetry of more than 2.3 Hz/generalized and focal runs of slow waves approaching background activity in amplitude.(b) Hyperventilation. Paroxysmal spikes and slow waves/spikes/focal spike pattern(c) Photo Stimulation. Bilaterally synchronous or focal paroxysmal spikes and slow waves persisting in post-photic stimulation period/suppression or driving response over one hemisphere.1.10.16. Non specific EEG abnormality will be acceptable provided opinion of Neuropsychiatrist / Neurophysician is obtained. The findings of EEG will be entered in AFMSF-2.CHAPTER 11EAR, NOSE AND THROAT1.11.1. Nose and paranasal sinuses.(a) Obstruction to free breathing as a result of a marked septal deviation is a cause for rejection. Post correction surgery with residual mild deviation with adequate airway will be acceptable.(b) Any septal perforation will entail rejection.(c) Atrophic rhinitis entails rejection.(d) Cases of allergic rhinitis will entail rejection for flying duties.(e) Any infection of para-nasal sinuses will be a cause for temporary rejection. Such cases may be accepted following successful treatment.(f) Multiple polyposis is a cause for rejection.1.11.2. Oral Cavity and Throat.(a) Candidates where tonsillectomy is indicated will be temporarily rejected. Such candidates may be accepted after successful surgery.(b) The presence of a cleft palate is a cause for rejection.(c) Any disabling condition of the pharynx or larynx including persistent hoarseness of voice will entail rejection.1.11.3. Eustachian Tube Dysfunction. Obstruction or insufficiency of eustachian tube function will be a cause for rejection. Altitude chamber ear clearance test will be carried out before acceptance for aircrew duties.1.11.4. Tinnitus. The presence of tinnitus necessitates investigation of its duration, localization, severity and possible causation. Persistent tinnitus is a cause for rejection, as it is liable to become worse through exposure to noise and may be a precursor to Otosclerosis and Meniere’s disease.1.11.5. Susceptibility to Motion Sickness. Specific enquiry should be made for any susceptibility to motion sickness. An endorsement to this effect should be made in AFMSF-2. Such cases will be fully evaluated and, if found susceptible to motion sickness, they will be rejected for flying duties.1.11.6. A candidate with a history of dizziness is unsuitable for employment on flying duties.1.11.7. Hearing loss.(a) Free field hearing loss is a cause for rejection.(b) Audiometric loss should not be greater than 20 db, in frequencies between 250 and 4000 Hz. In evaluating the audiogram, the baseline zero of the audiometer and the environmental noise conditions under which the audiogram has been obtained should be taken into consideration. On the recommendation of an ENT Specialist, an isolated unilateral hearing loss up to 30 db may be condoned provided ENT examination is otherwise normal.1.11.8. Ears. A radical / modified radical mastoidectomy, or a fenestration operation entails rejection even if completely epithelialised and good hearing is preserved. Cases of cortical mastoidectomy in the past with the tympanic membrane intact and presenting no evidence of disease may be accepted.1.11.9. External Ear. Cases of chronic otitis externa accompanied by exostoses or unduly narrow meatii should be rejected. Exaggerated tortuosity of the canal, obliterating the anterior view of the Tympanic Membrane will be a cause for rejection.1.11.10. Middle Ear. Tympanoplasty type I is acceptable twelve weeks after surgery, provided ear clearance test in altitude chamber is normal. The following middle ear conditions will entail rejection:-(a) Attic, central or marginal perforation.(b) Tympanic membrane scar with marked retraction.(c) Tympanoplasty type II onward but not type I(d) Calcareous plaques (tympanosclerosis) if occupying more than 1/3 of pars tensa.(e) Middle ear infections.(f) Granulation or polyp.(g) Stapedectomy/ Stapedolysis operation.1.11.11. Miscellaneous Ear conditions. The following ear conditions will entails rejection:-(a) Otosclerosis even if successfully operated.(b) Meniere’s disease.(c) Vestibular Dysfunction including nystagmus of vestibular origin.(d) Bell’s palsy.CHAPTER 12OPHTHALMIC SYSTEM1.12.1. Visual defects and medical ophthalmic conditions are amongst the major causes of rejection for flying duties. Therefore, a thorough and accurate eye examination is of great importance in selecting flying personnel.1.12.2. Personal and Family History and External Examination.(a) Squint and the need for spectacles for other reasons are frequently hereditary and a family history may give valuable information on the degree of deterioration to be anticipated. Candidates, who are wearing spectacles or found to have defective vision, should be properly assessed.(b) Ptosis interfering with vision or visual field is a cause for rejection till surgical correction remains successful for a period of six months. Candidates with uncontrollable blepharitis, particularly with loss of eyelashes, are generally unsuitable and should be rejected. Severe cases of blepharitis and chronic conjunctivitis should be assessed as temporarily unfit until the response to treatment can be assessed.(c) Naso-lachrymal occlusion producing epiphora or a mucocele entails rejection, unless surgery produces relief lasting for a minimum of six months.(d) Uveitis (iritis, cyclitis, and choroiditis) is frequently recurrent, and candidates giving a history of or exhibiting this condition should be carefully assessed. When there is evidence of permanent lesions such candidates should be rejected.(e) Cornea - corneal scars, opacities will be cause for rejection unless it does not interfere with vision. Such cases should be carefully assessed before acceptance, as many conditions are recurrent.(f) Cases with Lenticular opacities should be assessed carefully. As a guideline any opacity causing visual deterioration, or is in the visual axis or is present in an area of 7 mm around the pupil, which may cause glare phenomena, should not be considered fit. The propensity of the opacities not to increase in number or size should also be a consideration when deciding fitness.(g) Visual disturbances associated with headaches of a migrainous type are not a strictly ocular problem, and should be assessed in accordance with para 3.10.3 and 3.10.4. Presence of diplopia or detection of nystagmus requires proper examination, as they can be due to physiological reasons.(h) Night blindness are largely congenital but certain diseases of the eye exhibit night blindness as an early symptom and hence, proper investigations are necessary before final assessment. As tests for night blindness are not routinely performed, a certificate to the effect that the individual does not suffer from night blindness will be obtained in every case. Certificate should be as per Appendix “A” to this chapter.(j) Restriction of movements of the eyeball in any direction and undue depression/ prominence of the eyeball requires proper assessment.1.12.3. Visual Acuity/Colour Vision. The visual acuity and colour vision requirements are detailed in Appendix B to this chapter. Those who do not meet these requirements are to be rejected.1.12.4. Myopia. If there is a strong family history of Myopia, particularly if it is established that the visual defect is recent, if physical growth is still expected, or if the fundus appearance is suggestive of progressive myopia, even if the visual acuity is within the limit prescribed, the candidate should be declared unfit.1.12.5. Ophthalmic Surgeries. Radial Keratotomy, Photo Refractive Keratotomy / Laser in Situ Keratomileusis (PRK/LASIK) surgeries for correction of refractive errors are not permitted for any air force duties. Corneal Topography may be done in suspected cases. Candidates having undergone cataract surgery with or without IOL implants will also be declared unfit.Ocular Muscle Balance1.12.6. Individuals with manifest squint are not acceptable for commissioning.1.12.7. The assessment of latent squint or heterophoria in the case of aircrew will be mainly based on the assessment of the fusion capacity. A strong fusion sense ensures the maintenance of binocular vision in the face of stress and fatigue. Hence, it is the main criterion for acceptability.(a) Convergence(i) Objective Convergence. Average is from 6.5 to 8 cm. It is poor at 10 cm and above.(ii) Subjective Convergence (SC). This indicates the end point of binocular vision under the stress of convergence. If the subjective convergence is more than 10 cm beyond the limit of objective convergence, the fusion capacity is poor. This is specially so when the objective convergence is 10 cm and above.(b) Accommodation. In the case of myopes accommodation should be assessed with correcting glasses in position. The acceptable values for accommodation in various age groups are given in Table 1.Table 1. Accommodation Values - Age wise.Age in years 17-20 21-25 26-30 31-35 36-40 41-45Accommodation 10-11 11-12 12.5-13.5 14-16 16-18.5 18.5-27in cm.1.12.8. Ocular muscle balance is dynamic and varies with concentration, anxiety, fatigue, hypoxia, drugs and alcohol. The above tests should be considered together for the final assessment. For example, cases just beyond the maximum limits of the Maddox Rod test, but who show a good binocular response, a good objective convergence with little difference from subjective convergence, and full and rapid recovery on the cover tests may be accepted. On the other hand, cases well within Maddox Rod test limits, but who show little or no fusion capacity, incomplete or no recovery on the cover tests, and poor subjective convergence should be rejected. Standards for assessment of Ocular Muscle Balance are detailed in Appendix C to this chapter.1.12.9. Any clinical findings in the media (Cornea, Lens, Vitreous) or fundus, which is of pathological nature and likely to progress will be a cause for rejection. This examination will be done by slit lamp and ophthalmoscopy under mydriasis.HAEMOPOIETIC SYSTEM1.13.1. All candidates will be examined for clinical evidence of pallor (anaemia), malnutrition, icterus, peripheral lymphadenopathy, purpura, petechae/ecchymoses and hepatosplenomegaly.1.13.2. In the event of laboratory confirmation of anaemia (<13g/dl in males and <11.5g/dl in females), further evaluation to ascertain type of anaemia and aetiology has to be carried out. This should include a complete haemogram (to include the PCV MCV, MCH, MCHC, TRBC, TWBC, DLC, Platelet count, reticulocyte count & ESR) and a peripheral blood smear. All the other tests to establish the aetiology will be carried out, as required. Ultrasonography of abdomen for gallstones, upper GI Endoscopy/ proctoscopy and hemoglobin electrophoresis etc may be done, as indicated, and the fitness of the candidate, decided on the merit of each case.1.13.3. Candidates with mild microcytic hypochromic (Iron deficiency anaemia) or dimorphic anaemia (Hb < 10.5 g/dl in females and < 11.5g/dl in males), in the first instance, may be made temporarily unfit for a period of 04 to 06 weeks followed by review thereafter. These candidates can be accepted, if the complete haemogram and PCV, peripheral smear results are within the normal range. Candidates with macrocytic / megaloblastic anaemia will be assessed unfit.1.13.4. All candidates with evidence of hereditary haemolytic anaemias (due to red cell membrane defect or due to red cell enzyme deficiencies) and haemoglobinopathies (Sickle cell disease, Beta Thalassaemia: Major, Intermedia, Minor, Trait and Alpha Thalassaemia etc) are to be considered unfit for service.1.13.5. In the presence of history of haemorrhage into the skin like ecchymosis / petechiae, epistaxis, bleeding from gums and alimentary tract, persistent bleeding after minor trauma or lacerations / tooth extraction or menorrhagia in females and any family history of haemophilia or other bleeding disorders a full evaluation will be carried out. These cases will not be acceptable for entry to service. All candidates with clinical evidence of purpura or evidence of thrombocytopenia are to be considered unfit for service. Cases of Purpura Simplex (simple easy bruising), a benign disorder seen in otherwise healthy women, may be accepted.1.13.6. Candidates with history of haemophilia, von Willebrand’s disease, on evaluation, are to be declared unfit for service at entry level.1.13.7. Human Immuno Deficiency Virus (HIV). Seropositive HIV status will entail rejection.CHAPTER 14ASSESSMENT OF WOMEN CANDIDATES1.14.1 History. Detailed menstrual and obstetric history, in addition to general medical history, must be taken and recorded as outlined in para 2.13.2. If a history of menstrual, obstetric or pelvic abnormality is given; an opinion of gynaecologist is to be obtainedExamination1.14.2. General Medical and Surgical Standards(a) Any lump in the breast will be a cause for rejection. Cases of Fibroadenoma breast after successful surgical removal may be considered fit with the opinion of a surgical specialist.(b) Galactorrhoea will be cause for temporary unfitness. Fitness after investigation/treatment may be considered based on merits of the case and opinion of the concerned specialist.1.14.3. Gynaecological Disorders(a) Any abnormality of external genitalia will be considered on merits of each case. Significant Hirsutism especially with male pattern of hair growth will be a cause for rejection. Doubtful cases if any will be decided based on the opinion of the specialists.(b) A detailed pelvic sonography will be conducted. If any abnormality is detected, the candidate will be examined by the concerned specialist. Following conditions will not be a cause for rejection:-(i) Small fibroid uterus (3 cm or less in diameter) without symptoms.(ii) Small ovarian cyst (3 cm or less in diameter) as such cysts are invariably functional.(iii) Congenital elongation of cervix (which comes up to introitus).(iv) Congenital uterine anomalies such as bicornuate uterus, uterus didelphys and arcuate uterus.(c) Acute or chronic pelvic infection and Endometriosis will be causes for rejection.(d) Severe menorrhagia will entail rejection, since it is likely to interfere with work ability. Amenorrhoea without pregnancy will be investigated and fitness will be considered on merits after examination and investigation by gynaecologist.(e) Complete prolapse of uterus will be a cause for rejection. Minor degree, after surgical correction, may be considered for fitness on merits.(f) Any other gynaecological condition not covered above will be considered on merits of each case by gynecologist.(g) Pregnancy will be a cause for rejection during commissioning for all branches other than medical and dental, where temporary unfitness will be given till 24 weeks after delivery.THIS IS THE MAX I COULD DO TO BAFFLE UP ANY CANDIDATE OVER THE MEDICAL REQUIREMENTS. ^_^ XDCourtesy : http://dgcamedicals.in/IAFMedstd.htm