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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.”