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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.”

This is a good question. First, let’s identify the problem for which an answer is needed; other answers have gone into some pretty hefty detail about what the problem is not, so I will skip that.Among the top 20 countries ranked by the Human Development Index, the United States ranks #5, placing it firmly in the “highly developed” bracket on a number of metrics such as infrastructure, standard of living, political stability, rule of law, etc. However, the United States leads the top 20 nations in the “developed world” in total homicide rate:Numbers from UN Human Development Report: Homicide rate (per 100,000)It’s not even close; despite a downward trend, the U.S. doubles the homicide rate of the next closest country each year. The next most developed countries matching this homicide rate are Estonia and Lithuania, ranked #33 and #35 respectively, and both with a recent history of continuing civil strife after the Soviet breakup, which has improved dramatically from 2000 to 2011 (both countries averaged about 10.5 per 100k homicides in 2000, and that had been cut in half in Estonia and nearly in half in Lithuania by the end of the decade).Using more recent numbers from 2015, the firearm-involved homicide rate was 3.2 per 100k, while the total homicide rate was 3.82 per 100k. So, the U.S. is about double the total homicide rate of Canada and about three times the total homicide rate of the UK and Australia, and guns are involved in 83% of those U.S. homicides, while numbers in other developed countries with strict gun control policies are closer to 20–35%. Naively speaking, if we banned all the guns and went door-to-door to confiscate them, got our gun-related homicide rate down to that of Canada (0.5 per 100k), and our non-firearm homicide rate didn’t move, we’d have a total rate better than Canada’s (1.12 vs 1.44).However, that’s naive because we’ve not seen any such result from any other country that has recently banned guns. UK’s total homicide rate spiked (even when removing an “anomalous event” from 2002’s numbers) and took ten years and a bunch of other restrictions on other weapons (especially knives) in order to return to pre-ban levels. Australia’s firearm-related homicide rate remained relatively steady, and the downward trend in total homicides the country has seen is largely due to a decrease in non-firearm-related homicides.In both cases, these countries’ homicide rates have historically been much lower than the United States’, before and after their gun bans. So, guns were never really the problem in either country in the first place (in fact, even with the Port Arthur mass shooting, 1996 was the quietest year in decades for Australia in terms of firearm deaths).So, clearly, banning guns doesn’t keep people from killing each other, including with guns. This is the argument against gun control in the US; it has not been shown to actually solve the problem, either within the U.S. or anywhere else.Just as clearly, the United States has a deeper underlying problem with violence that these other countries do not. What is that problem? To find that out, let’s slice and dice the United States’ homicide figures. Here’s the homicide rate by jurisdiction:Comparing this to Brady scores (a metric compiled by the Center for Gun Violence Prevention that rates a jurisdiction’s level of gun control), we see zero correlation between gun control and homicide rate:The top is a ranked plot, the bottom is plotted by raw score. As you can see, at nearly every level, there is zero significant correlation between gun control and gun crime; the safest and most violent jurisdictions are roughly evenly scattered across the spectrum of levels of gun control legislation. The only thing we might be tempted to say about gun laws is that they normalize gun crime levels; as the level of gun control increases, the violent crime rate tends to converge and become more predictable. The average amount of violent crime, however, remains largely unchanged.So, gun control isn’t the answer. What, then, does correlate strongly with the homicide rate?Poverty? Not really:No real correlation in these trends (though it should be noted that this graph uses the violent crime rate, which includes homicides but also assaults, robberies, rapes and a couple other crimes against the person); during a time of relative economic stability among the rank and file as evidenced by poverty rate, violence peaked and then fell off. If anything, there’s a weak negative correlation; the poorer the nation is overall, the less people want to rob, rape, beat or kill each other.Income Inequality? That has a stronger correlation:As the Gini Coefficient of Wealth increases, we tend to see a proportional increase in the homicide rate. This generally points to a biblical truth; the love of money is the root of all that kills. When you’re doing about the same as everyone else, no matter how well or badly that is, there’s no real reason to try to take anyone else’s stuff by violence. When a very few people are showing off what’s possible in a society, and everyone else is struggling to make ends meet, there’s more motivation to get ahead by any means necessary.Population Density? Kind of:This is a distribution heatmap of homicides, which correlates closely with the population density heatmap. All this really tells us is that more murders happen in the counties with more people; bravo CPRC, well done, have a cookie.Here’s a much better map of the per-capita firearm homicide rate by county (not total homicides, though as mentioned firearms are used in about 83% of homicides), although some counties are excluded because the population is too small for the rate to be statistically meaningful:This shows a slightly clearer picture. Yes, major cities tend to have worse murder rates per capita, but that’s not the whole story; homicide rates are also higher across the Deep South, whether urban or rural, and there are higher rates in the Southwest as well.Minority population? This is where things get really interesting, and also extremely politically incorrect:This is a chart of the highest Hispanic-population cities over 500k in the U.S. If anything, there’s a negative correlation here; the higher the Hispanic percentage, the lower the violent crime rate. However, look at the other two sets of bars. Population identifying as white correlates pretty closely to the violent crime rate. That’s not all; the population identifying as black correlates pretty much exactly with the homicide rate.Is there a wider correlation?Yes there is.Now, let’s all calm down and take a step back. I’m not implying some hard-wired racial propensity for violence; black people are not the cause of all the U.S.’s violence problems. Once again, the problem is down to inequality of wealth and economic opportunity:Across the board, regardless of education level, blacks are less employed and less well-paid, and as a direct result, their median family wealth is ten percent that of the median white household net worth. Education trends simply reinforce the cycle; black people are less financially able to send their kids to college, so naturally they will have a lower percentage of college attendance and graduation.The answer? Close this gap. Equal employment opportunity and equal pay for equal work can’t just be pretty words; despite decades of trying, the numbers are clear that white men have an advantage across the board, largely due to systemic implicit racial bias in the working world. Affirmative Action was struck down as being “reverse racism”, and that wasn’t an incorrect assessment; hiring managers especially in the public sector were told to explicitly favor minority applicants over more well-qualified white applicants. That’s not right either.The real solution is education, and by that I mean we need to educate people in positions of authority, at every stage of human interaction, about the existence of implicit bias. If you asked them, up front, whether they consider race as a part of their decision-making regarding the people they have authority over (students, job applicants, current employees, patients, criminal defendants), to a person they’d say “no”. But, they do, they just don’t consciously know they do. Case studies of nameless hypothetical patients given to practicing physicians, in a manner not unlike various board tests administered in the industry, showed a clear bias in decision making due to race, with detrimental effects on patient health for minority patients. When shown the results, the doctors participating in the study were horrified at the effects their choices had. None would have considered themselves racist, and they’re not; they’re just subject to the same cognitive biases that have dominated human decision making since the rise of civilization.The solution is better education among decision-makers on these implicit biases; simply knowing they exist and are significant in the important decisions you make is half the battle. Cognitive bias and other “shortcuts” in human decision-making are Psychology 101, but that’s one class, typically an elective at that, in one semester of higher education that not everyone gets, which is supposed to counter not only 12 years of ignorance on the topic in the curriculum of most public schools, but tens of thousands of years of human cognition development built around these biases as a useful, even necessary shortcut to prevent “analysis paralysis” when encountering a novel situation. We’re really talking about constant reinforcement through continuing education, providing a constant pressure to counter our internal tendency to “go with our gut” even in totally objective decision-making situations.And, this education can’t be sensationalized the way these things tend to be. A journal article on the topic published by the scientific community might be titled “A statistical analysis of implicit racial bias in decision-making among employers and other positions of authority”. Newsweek or Time magazine will pick it up and run with the headline “Your Boss Is Racist”. That doesn’t help anyone; very few in mainstream society today consider themselves (or their bosses, for that matter) to be card-carrying white supremacists. So, most would facially reject the stated thesis without even reading the article, and if someone does read the article, they would begin from a position of incredulity, not concern. If you want to get people’s attention, a better headline would be, “No, You Aren’t Racist - But You Still Act Like One”.More reading:Guns, Crime, Homicide, And Gun Ownership: Statistical TrendsCombating Implicit Bias In The Workplace - Law360Understanding Implicit Bias (written for teachers/educators)

Many jobs never “left” the United States, they were simply automated away…If you've got the time, I *STRONGLY* recommend reading the Adam Ruins Everything episode on “Adam Ruins the Economy”. It's $1.99 commercial-free on YouTube, but free (with commercials) on TruTV:Anyways, the US still manufactures just as much as it ever did (in absolute terms, not in terms of the ratio of manufactured goods consumed to produced)— it just makes those goods with a FRACTION of the labor it once did…In terms of why the US hasn't maintained its domestic market-share in manufacturing, and many other industries, though, there are several reasons:Free Trade and reduction of trade tariffs. Don’t let ANYBODY ever tell you that offshoring of factories is a new concern. It's not. As far back as the early 1800's, wealthy American Manufacturers were concerned about being out-competed by manufacturers in countries with cheaper foreign labor at their disposal. Their response: DEMAND the government leverage hefty trade tariffs of foreign-made goods. These tariffs were leveled, ironically with the support of the same kinds of “pro-business” elements that most strongly favor Free Trade today (their opponents stood for rural America- at the time rural America's economy was built on farming, and Farmers suffered under trade barriers as they had to pay more for manufactured goods, and had fewer markets to sell their food in when foreign powers inevitably retaliated with tariffs on US agricultural products), and American Manufacturing had a chance to grow past its infancy without being ruthlessly crushed by foreign competition. Free Trade generates more wealth than Protectionism, but with a VERY important caveat- the people who gather the lion's share of those gains are always those who control the most investment Capital. For the first century of American history, that was foreigners- paparticularly wealthy Europeans. It wasn't until the turn of the century (around 1900) when that really began to change, as America had developed its own wealthy and powerful banking elite- and notably, that is also when the Free Trade movement really began to find its footing…Rising wages in the USA. Thanks to the efforts of labor unions (which I sympathize with- every worker deserves a livable income- but these efforts also helped drive jobs overseas) and Minimum Wage laws, American wages rose *FAR* beyond the “market price” of labor in the US, which would generate full employment and stimulate less offshoring than we've seen thus far in our history. There were MANY beneficial effects for the country from a more equitable distribution of income, and in past decades where offshoring was harder it wasn't such a big deal (plus, offshoring of factories isn't ALL bad- they also take their pollution overseas with them. Have you ever SEEN the air in Beijing? You could choke on it…) but there were also much better ways of attaining a more equitable distribution of income than raising the Minimum Wage that were neglected. In particular, I'm talking about Wage Subsidies and a modest Universal Basic Income- it's better to give people money directly from tax revenue (funded by taxes the rich can't get out of simply by laying off workers, or moving the factories overseas- as long as the profits come home, they are still taxed…) than to FORCE employers to pay their workers more- which will just ultimately drive the jobs overseas…Foreign subsidies to businesses. Many countries which have built their economies on exporting goods to the USA have taken to handing large subsidies to businesses to do so. These are often not “explicit” subsidies (I'll give you money to do business here), but “effective” subsidies- where the governments have allowed manufactures to generate enormous economic “externalities”— such as heavy pollution, and deaths due to unsafe working conditions- and offload those very real financial coats onto the general public at no cost to the manufacturers. If I, a city government official, allow you to pump so much pollution into the air that 20 million people have to spend $50 a year on face masks just to breath, and impose no financial penalty on you for doing so, I am effectively handing you $1 billion a year in subsidies on the cost of doing business in my city without ever directly giving you a cent. For more on this, I suggest reading up on the concept of Economic Externalities: Externality - Wikipedia, Externality- Investopedia, Externalities - DefinitionLack of US educational competitiveness. When corporations are looking for a country with a highly-educated scientific or technical workforce, the country that makes the top of their list isn't the US- it's countries like South Korea or Germany, which have the highest rates of STEM graduates in the world (32% and 31% of college graduates, respectively— to only 16% in the US). In the vein of talking about Economic Externalities, there is one important POSITIVE Externality that people often neglect to mention- Education. Society and private citizens shoulder the costs of educating a country's citizenry, but they are often not fully repaid for the investment by corporations that reap much higher Productivity (which I will here use a working definition for of economic value produced per hour worked) as a result. Fortunately, high Education levels generate positive externalities in many other aspects of society than simply increased Productivity- from reduced propensity to Crime, to the ability to make better political decisions at the voting booth (there is a reason, I would argue, highly-educated people were less likely to vote for Donald Trump than uneducated people with otherwise identical demographics…), to an ability to live a more fulfilled life (an Education in the arts, history, and literature may not hold much economic value- though it does hold some- but I would argue it certainly is an aid in living a more meaningful life…) So it probably still makes sense for societies to heavily invest in Education- even if corporations don't fully compensate them for the investment (most of the increased profits a corporation makes off employing an already-educated workforce represent economic value this societal investment created that is being kept by the corporate capitalists rather than paid back to the society that generated the human capital in the first place…) but it would make even MORE sense for societies to invest in better-educating their future workforce if those societies got to keep more of the profits generated by this human capital investment for themselves…The US simply isn't making the investments it needs to- in science, technology, infrastructure, healthcare, or education (not all of which I had time to discuss today)- and on top of that it's continuing to maintain some of the highest wages in the world and provide a (rightfully) hostile regulatory environment for polluters. All of this is POISON to the USA’s chances of regaining competitiveness in global markets. In order to bring jobs back, the US needs to implement SEVERAL policies simultaneously and in a wisely-planned fashion:Slash the Minimum Wage and replace the cuts with wage-subsidies. The Minimum Wage cuts are necessary to make employing American labor more financially appealing (the Minimum Wage doesn't just increase wages for the handful of workers who actually work for it- but for a whole ladder of paid jobs that seek to draw workers away from Minimum Wage jobs with slightly higher pay, and from those jobs in turn with higher pay still, and so on and so forth…), and the wage-subsidies are necessary to avoid creating massive economic crisis by suddenly dropping the bottom out on US Consumer Demand. More evenly distributing income also generates a host of Positive Economuc Externalities- including lower Crime rates, lower levels of stress and anxiety (and occasionally resultant physical and mental health crises, and suicides) across the population, and higher levels of private investment in Education for the next generation…MASSIVELY increase US government support for Education. Educational investment by the goveenment is, as mentioned, one way of subsidizing business enterprises without directly costing the corporations money. *Especially* if those educational investments are funded through increased taxation on the wealthy ownership class through higher Capital Gains Taxes- taxes they will have to pay one way or the other so long as they remain US citizens: regardless of whether they locate their factories and laboratories on US soil, or abroad…Reduce the US Corporate Income Tax Rate. Corporations in the United States pay a Corporate Income Tax on their profits BEFORE they hand them off to shareholders as dividends. This is largely a needless form of double-taxation (domestic shareholders are hit first with the Corporate Income Tax, and then again with the Capital Gains Tax) that also serves to discourage foreign investment in the US economy (foreign shareholders are not necessarily subject to the Capital Gains Tax, but they ARE subject to the Corporate Incone Tax) . It serves SOME purpose by raising revenue from foreign investors and paying for some of the Negative Economic Externalities generated by doing business (although this is a crude and inefficient tool that disproportionately affects manufacturers of high-profit goods and ignores polluting companies barely breaking even- compared to direct fines on polluters)- but largely it just serves to drive investors to plant their Capital elsewhere (including driving US stockholders to invest overseas)… It would be ideal to cut the Corporate Income Tax to a fraction of its current value for standard, c-class corporations (s-class “pass-through” corporations such as Trump's real estate empire have no shareholders, and are often ALREADY used as a mechanism to dodge taxes vs. just owning a corporation privately and paying oneself an enormous salary— their taxes should NOT be cut, for reasons too complicated to explain here…) and shift much of the tax burden to the Capital Gains Tax…Create a US Sovereign Wealth Fund, and invest its Capital domestically. The downside of raising the Capital Gains Tax is that it slightly discourages private savings and investment in the stock market (the enormously-wealthy already have more money than they could possibly spend, and would just stick in in stocks/bonds anyways because they have nothing better to do with it. However the slightly-less obscenely wealthy will see a reduced benefit from putting aside money in investments to be cashed in at some point in the future, and choose to spend the money now instead- which contrary to popular belief, is NOT a good thing in the long run…) This can be compensated for by the creation of a US Sovereign Wealth Fund- funded by hikes to the top brackets of the Income Tax and Capital Gains Tax (if those wealthy individuals never bring home the money in the first place, they don't have the opportunity to spend it) as a form of forced-investment for the greater good of society. Essentially, a Sovereign Wealth Fund is a government-owned investment fund which can either be managed by government investors or contracted out to existing private investment firms (preferably the former- as private investment firms have repeatedly demonstrated their willingness to put their own interests ahead of their investors’). Instead of the returns going to any private individual they go to the government that owns it- where they can be invested back into growing the Sovereign Wealth Fund (as they largely should be given the situation of the US right now), used to offset tax-cuts years after the money was initially invested, or spent on other government programs such as infrastructure and education. Just as importantly, since the US government is essentially investing in creating jobs and profits (for other investors) somewhere in the world with its SWF investments, it can direct that the funds be invested here in the US rather than abroad- even if this results in lower direct returns on the SWF investments. The US government also gains tax revenue from the jobs and profits generated under this scheme, and may actually generate more total revenue this way- despite generating smaller direct returns in the US (in the broadest economic terms, less total wealth is generated this way- but ALL of it stays in the US- rather than some of it going to benefit foreign workers with better-paying jobs, resulting in larger total gains for the US. In the broadest possible sense, it is a true “Anerica First” policy…) A Sovereign Wealth Fund can alternatively be used as a form of soft power- the US government only allows its SWF managers to invest in countries that behave in a manner pleasing to the US (not Russia after interfering in our elections and invading the Crimea, for instance), and divests from countries that turn on it- a tool much more effective than economic sanctions- which unscrupulous businessmen, (the likes of Paul Manafort- who was recently indicted on charges related to laundering money for Russian interests) will only be all to happy to try to find ways around- unlike US government investment managers, whose interests would be *MUCH* more closely aligned with those of the government… (people generally give their loyalties to whoever pays their paycheck, a sad fact but true…)Match US tariff regimes more closely to those on American goods- avoid Free Trade for its own sake. Free Trade generates more wealth than tariff-burdened trade: even when it is non-reciprocal. But the wealth generated isn't necessarily divided EVENLY between nations- if one nation fails to tax foreign imports, even as its own foreign imports are heavily taxed, it can often end up WORSE off than if the tariffs had run both ways, even if the net wealth generated is greater. In Game Theory, it's a version of the Prisoner's dilemma- except one where one side cooperating and the other betraying produces a better net outcome (although worse for the losing player) than if both sides has behaved non-cooperatively… And like with the Prisoner's dilemma, the best strategy in an iterated game is generally some variant of “Tit-for-Tat”. The job of US politicians is to put the interests of US citizens first (within limits), and providing other nations with more economically-important trade concessions than they provide us (although, contrary to populist claims, these trade deals are usually not GROSSLY lopsided, they rarely do enough to reduce tariffs on US agricultural goods and improve protections for US intellectual property in exchange for low or nonexistent tariffs on foreign manufactured goods…) is NOT placing the interests of US citizens first. I invite a global perspective as much as the next person- but the way to accomplish global goals for economic growth is through trade rules set by international organizations like the United Nations (which the US should *NOT* seek to control and force to act in its best interests alone- as such behavior ultimately undermines the organization and its hard-won moral authority…) not through unilateral actions by US politicians bolstered by the overstated ideology that “a riding tide lifts all boats” (this is only true to a very LIMITED degree, and generally only a cop-out from making wise decisions- there are still winners and losers in a global economy, and the differences can be quite drastic…)If the United States made just these five changes, it would go a LONG way towards bringing more jobs to the US. They might not be the SAME jobs as before, but many of them would be GOOD jobs.And this is all without even TOUCHING on other critical issues- like fixing the US health insurance system (which is largely broken due to a history of insurance company mergers and rampant price-gouging, as well as out-of-control insurance company bureaucracy targeted at avoiding paying up on legitimate claims that customers understood they would receive coverage for when they bought their insurasnce…), averting the impending doctor-shortage by training more medical students and residents (this would not only create more jobs in medicine in the US by slowing the growth of physician salaries- it would also end the need to steal doctors from countries like India and Canada with higher salaries- which directly harms those countries, and leads to those doctors sending considerable wealth back home to assist relatives outside the US…), and increasing government investment in public scientific research and development…In short, the US needs to make BIG changes to bring more jobs to the country- and these changes cannot be made overnight.The fault for our current situation does not lie with the workers (aside from voting in the wrong leaders, not being aggressive enough in pursuing higher education, and demanding the wrong changes), but with the system— and the changes that need to be made are not miraculous cure-alls, but will require hard work and sacrifices today (such as higher taxes- particularly on the rich), in order to secure a better future…