Nouvelles et analyses

Shut out at home, flocking to ’s medical schools — and to an uncertain future

Patrick Sullivan

anada has a 17th . C It’s located several thousand kilo- metres east of Newfoundland, and it has become a haven for Canadians who find it difficult or impossible to enter 1 of ’s 16 schools. The Atlantic Bridge Program, which recruits North American med- ical students for the Irish schools, says more than 100 Canadians are currently enrolled in medicine at University Col- lege Dublin, University College , Trinity College Dublin and the Royal College of Surgeons in Ireland. They outnumber the first-year students at 9 of Canada’s 16 medical schools, and their total is roughly double the size of the first-year class at the University of . Twelve of the more than 100 Canadians now studying medicine in Ireland These young expatriates — most are in their mid- to late 20s — appear un- And there may be reason for at least Canadians’ are more likely to be suc- deterred by annual tuition fees of some optimism. “It is difficult to pre- cessful than some others.” $30 000, high living costs, the prospect dict where we are going as far as oppor- She also notes that completion of a of huge debt loads and uncertainty tunities for IMGs [international med- Canadian is not the only route about their professional future. None of ical graduates] in Canada are to a practice in Canada. “If they have the students interviewed by CMAJ ex- concerned,” says Sandy Banner, execu- completed some postgraduate training pressed any doubts about the route they tive director of the Canadian Resident somewhere, they should remember that have chosen, but all have doubts about Matching Service. “I believe there will more than 700 limited licences [they re- whether they will ever be allowed to be an expansion of our postgraduate strict the location of practice and/or practise in Canada. Still, the outcry training complement in the near future, type of practice] were granted to IMGs over the country’s physician shortage and as there are no additional Canadian in Canada in the last short while.” has left many of these “” grads yet, these positions will be filled All of this is good news for feeling optimistic. by more and more IMGs. But remem- natives Michael Bengough, 25, and Kim “I expect at some point to have the ber, that’s just a prediction — none of Wynd, 26, who are in the third year of a option of practising in Canada, whether this has come to pass.” 6-year program at University College I do my residency there or elsewhere,” However, support for such a move is Dublin (UCD). Odds are good that this says Jason Blair, 28, of Manotick, Ont., growing. Last fall the Canadian Med- married couple would eventually have a second-year student at the Royal Col- ical Forum, which includes the CMA, been accepted by a Canadian school — lege of Surgeons in Ireland. “I say this issued a call for an increase in the num- their respective MCAT scores were 34 because I believe there will be a short- ber of government-funded training po- and 30, both had first-class honours age of doctors, even if the government sitions from the current level of 100 while undergraduates and both hold acts now to increase enrolment. slots per 100 medical school graduates master’s degrees. Bengough had received “In the coming years, I think the to 120/100. an interview at Queen’s and Wynd was government will have to attract doctors Banner notes that there was no ex- on the waiting list at Western. from outside the country. In a sense, I pansion for the residency match that So why Ireland? “Chances were not bet on this by deciding to go to school took place earlier this month. However, good that we would both be accepted abroad. This could turn out to be she says a few more IMGs are being into the same [Canadian] school in the overly optimistic, but I am an optimist.” matched each year, “and the ‘Irish same year,” says Bengough. “Moreover,

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© 2000 Canadian Medical Association or its licensors News and analysis

every year that we spent reapplying to from UCD in 1999 and is completing dent at UCD, replied: “On the con- Canadian schools pushed the com- an internship year at St. Vincent’s Hos- trary. I feel like I’m getting the best of mencement of our real lives — home, pital in Dublin. “The medical schools both worlds: studying medicine and family, et cetera — back by a year.” here are of tremendously high quality.” learning about another country and Maureen Keenan, 28, another third- Jason Blair agrees. “Someone said culture. I think we’ll bring something year student at UCD, offers similar rea- that for every spot in medical school in back to Canada from the Irish approach sons. She had been interviewed by UBC Canada, there are 4 qualified candidates. to medicine and life.” and was encouraged to reapply because I simply see myself as 1 of the 3 who lost But will Canada want them back? she was considered “a very strong candi- the draw. As far as the training I receive Dr. David Hamilton hopes so. date.” When she was accepted by UCD, here, I feel that it is as good as or better she decided to take that offer rather than what I would receive in Canada. Stuck in limbo between than risk rejection again. This school has been training some of Syracuse and Is there a stigma attached to having the world’s best doctors for 250 years.” to attend school outside Canada? “I do Asked whether she felt there was a Even though his career is currently not feel inferior at all,” says Calgary na- stigma attached to her education, 25- on hold as he awaits word of a resi- tive Dr. James Stone, 29, who graduated year-old Sara Junaid, a second-year stu- dency in Canada, the wait is giving him

“If Canada doesn’t want us, somebody else will” How did Victoria resident Ilana train in Canada have a better chance of ski will ever hang her shingle in Porzecanski end up in the fourth year of getting a residency position than Cana- Canada, even though that’s what she’d a 6-year medical program at University dian citizens who train abroad. love to do. “As an Irish graduate, I College Dublin? “Two reasons,” she “Right now, the situation is this. We would be welcome in New Zealand, says. “Mainly, they accepted me, and I cannot get residency training in Australia and Europe,” she says. “If I didn’t know when or if UBC would. Canada, except perhaps in our end up specializing, I will go to the US. And I was desperate to study medicine. province of origin.” Porzecanski says I am thinking strongly of moving there I didn’t want to settle for anything less she would have to spend 1 year estab- permanently.” than my dream of being a physician.” lishing residency, then 36 weeks doing Has the tough and expensive road Porzecanski, 28, was to medical training been probably on the borderline worth it? Porzecanski isn’t for acceptance at a Cana- sure. “I thought my problems dian school — she ended would be over once I got into her undergraduate years medicine, and life would be with a B+ average and had a perfect. But now I feel that the combined total of 26 in the problems are just starting.” 3 major components of the She has wondered if she MCAT. Since moving to Ire- should have entered another land in 1997, she has been profession such as law, which in the top 20% of her class. would have allowed her to stay Porzecanski expects to in Canada and receive Cana- owe $175 000 by the time dian financial support. But she she graduates. She receives says her attitude always about $6000 a year in fed- changes after she spends a day eral student loans, which “in the clinics. I’m so happy helps cover living expenses, Ilana Porzecanski: “Don’t forget about us.” and energized then that I’m but she is ineligible for sure I made the right choice. provincial funding because she is a clinical rotations, then write an exam “Would I do it again, knowing what medical student studying overseas. and do a clinical skills exam. “Then, I know now? Yes. All of the Canadians Her tuition costs $28 000 a year, only the top 4 candidates get to do a 6- here are optimistic that things will work while living expenses amount to $1400 month pre-residency rotation. Then, out in the end, because if Canada does- a month; her interest payments cur- only the top 2 candidates are offered a n’t want us, somebody else will.” rently total $350 a month. She is not 2-year family practice residency.” (She Does she have any message for sure if she will ever practise in Canada, outlines her own proposal in a letter to Canada’s doctors? “Don’t forget about where both her parents are physicians, the editor in this issue. — Ed.) us,” she says. “Give us a chance to and is bitter that foreign nationals who So odds appear slim that Porzecan- come back to Canada to train.”

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a chance to spend time with his wife Paras Naik, MD: How Scotland produced and 2 young children and to reflect on the differences between medicine in Canada’s youngest physician Canada and the US. If Paras Naik was a typical Cana- Hamilton, who graduated from the dian student, odds are he would be en- Royal College of Surgeons in Ireland 3 tering medical school in Canada in years ago, had completed 2 years of a September instead of graduating in residency at the State Uni- June from the University of Glasgow. versity of New York in Syracuse when, At age 22, he’ll become the youngest for family reasons, he decided to seek to Canadian to hold a medical degree. finish his residency in Canada. His wife, Naik had all the right credentials for Dr. Catherine Mann, is completing a pursuing a here: a psychiatry residency at the University 94% average in his final year of high of Ottawa. school in Markham, Ont., and accep- He arrived back in Canada after tance into undergraduate studies at the hearing “through the grapevine” that University of , McMaster and the Ontario Ministry of Health was Queen’s. awarding some residency positions on a So why did he leave? “With the visi- case-by-case basis if a community ble cutbacks in enrolment in the early showed a demonstrated need. Hamilton 1990s, the idea of studying medicine Paras Naik: Canada’s youngest doctor outside Canada became a clearer op- may never practise here then got in touch with officials in tion,” says Naik. “With the possibility Thunder Bay, Ont., who agreed to fund of completing a bachelor’s degree With that in mind, he intends to the last 2 or 3 years of his residency in without any guarantee of entry into a spend another year in the UK in order Canada in return for a commitment to Canadian medical school, it seemed to gain certification from the General practise in that Northern Ontario city. that my desire to get a medical degree Medical Council and make some However, his transfer to a residency would be easier to realize outside my money. “I will [then] make my best en- program at the own country.” deavour to get a residency in Canada.” has yet to be approved by the province. He responded by contacting 10 He’s not holding his breath. In No- “Do I have any regrets? In the grand medical schools in the UK and Ireland vember 1999 he wrote to 4 Canadian scheme of things, no, because it’s great in 1995, and chose Glasgow’s 5-year residency directors whose programs to be here with my family. If this [resi- program over the 6-year program in Ire- were unfilled in the 1999 match. “I ex- dency application] does fall apart, then land. By the time he receives his MB pressed my interest in their programs I’m going to apply as an IMG.” ChB degree in 3 months, he expects to and requested further information and Ontario currently provides 24 resi- owe £82 000 (Can$184 500). “As a advice. To date I have not received any dency slots for graduates of foreign med- child of a single-parent household, I acknowledgement.” If his attempts to re- ical schools, but there are rumours that have found it very challenging to fi- turn for Canadian training fail “it looks the number will rise shortly. Hamilton nance my education here,” he says, very likely that I will enter residency says he always has the option of moving “and a deteriorating exchange rate has- training in the US and practise there.” n’t helped. Financial matters have been Naik finds this ironic, given to the US, but he has no desire to do a constant stress for my mother and me Canada’s current physician shortage. “I that. “I simply think that our system is for the past 4 and a half years. I am just would like to emphasize what I felt superior,” he says. “In Syracuse I didn’t glad that the financial burden will be when I left Mount Sinai Hospital on like managed care at all — it forces put to rest in a few months.” Aug. 27, 1999, after the last day of my physicians to play games with the insur- So what does the future hold for Paras Canadian elective in . ance companies.” And even though Syra- Naik, MD? As graduation approaches, After being well looked after during my cuse is just a 2-hour drive from the Cana- he’s not sure. Although he would like to stay, I could not believe that I would dian border, “the cultural differences are practise in Ontario, the deck is clearly never be able to return to this institu- huge — it’s a different world there.” stacked against this. Naik notes that he, tion. I wasn’t told that this was the Hamilton, who went to Ireland after like all foreign medical graduates, can case, but I just knew that it was a dis- failing to gain acceptance at an Ontario apply for only the second iteration of the tant and rare possibility. As I slowly school, says he was fortunate to leave residency match — his Canadian citi- paced to my car, I gave one glance Ireland without major debts, thanks to zenship provides no advantages. “I feel over my shoulder at the hospital and financial help from his father. that securing a residency post will in- asked myself: ‘When will this ever As for the future, he hopes to be deed be challenging and will lead to a make sense?’ To this day I still haven’t working again within a year — and with great deal of frustration and time delay.” been able to answer that question.” any luck he’ll still be in Canada. Asked if he had a message for Canada’s doctors,

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he said: “There are a lot of Canadians “I expect to be in hock up to my eye- tial, but this is still cheaper than study- [trained in Ireland] who want to practise balls for a while after graduating,” says ing medicine in the US.” in Canada, anywhere in the country.” 24-year-old Aamir Jeewa, a third-year Bengough and Wynd expect to owe Indeed, Canada remains a magnet student at UCD. Although she does get $250 000 when they graduate, but for most of these students. Stone says some Canada Stu- Wynd explains that he would return to Canada if he could, dent Loans, this is this only represents but residency training raises huge ques- “only a drop in the half of the actual cost. tions, particularly because he wants to ocean.” It costs most “The rest is being be a surgeon. He has applied for a sur- Canadian students provided by our fam- gical residency in Ireland. “The most between $45 000 and ilies, for which we are important thing to me is to be a sur- $50 000 a year to at- eternally grateful.” geon, and if that means I cannot train tend school in Ire- Jason Blair, who or practise in my own country, then I land. Jason Blair, for scored a 31 on the will have to go elsewhere.” instance, expects to MCAT, had a 3.5 Asked if he had a message for Cana- owe around $300 000 grade point average at dian doctors, he said: “Canada spends by the time he gradu- McGill and finished plenty of money educating doctors who ates. He is financing in the first quartile of will not practise in Canada. To date I his studies through students in Western’s have cost the system nothing. And I am savings — he worked MBA program, was a Canadian. I always have been and I al- for a year after com- Michael Bengough and Kim asked if he had a mes- ways will be.” pleting an MBA at Wynd: Ireland provided a chance sage to pass on to Western — and bank to study medicine together Canada’s physicians “In hock up to my eyeballs” loans, “but the ma- and politicians. jority is a loan from my parents.” “There is a group of dedicated and The major concern for most of the Meanwhile, Don Wakelin, a 26- motivated Canadians studying medicine expatriates is rising debt loads. Foreign year-old University of Victoria gradu- abroad. Most, if not all, would like to students there pay about 3 times more in ate who enrolled at University College come back to Canada. Please make it tuition fees — about $30 000 annually Cork in 1996, is philosophical about easier for us to decide to return.” — than the most expensive Canadian the debt of $146 000 he expects to medical school, and the fees are accom- amass. “The financial assault incurred Patrick Sullivan is CMAJ’s News and panied by Europe’s high cost of living. with an overseas education is substan- Features Editor.

Irish schools actively recruiting Canadians Peter Nealon is building a bridge be- we say that the schools in Ireland are ans graduate? “Their best bet is to get tween Canada and Ireland, one medical your best bet if you don’t get in to a into the States,” he says. For non-US student at a time. Nealon is director of Canadian medical school.” citizens, this means they must be fully the Atlantic Bridge Program, which was He’s impressed by the quality of the licensed, so the Canadians should plan created by Ireland’s medical schools to Canadian students, almost all of whom on doing an internship year in Ireland. attract medical students from North have been rejected — some more than Once that is done, explains Nealon, it America in the face of growing competi- once — by schools in Canada. About is relatively easy to land a residency po- tion from offshore medical schools in half of these applicants are eventually sition in the US because the country the Caribbean and elsewhere. The 10- accepted by an Irish school. Nealon has about 22 000 residency slots but year-old program acts as a clearing- says the Canadian standards “are very produces only 15 000 new doctors a house for North American students in- high” and the students who go to Ire- year. “The Irish students get snapped up terested in studying medicine in Ireland. land almost invariably do well. for the good residencies,” he says. The number of calls it’s getting from “We’re fairly straightforward,” he “There’s an interesting angle to this,” Canadians is increasing in lockstep with says. “We get about 300 applications a he added. “Some of the applicants from the decline in the number of first-year year from North America. We could Canada tell us that they ‘just want to be positions at Canada’s 16 medical probably get 1000 if we wanted to, but doctors’ and they’ll worry about issues schools. “In the last 2 to 3 years we we counsel the ones we think couldn’t like residencies in 5 or 6 years. But some have noticed an increase,” says Nealon, cut it and advise them that they might of them have everything planned out in who now receives about 70 applica- be wise to pursue something else.” advance, and they tell us that they tions a year from Canadians. “Basically, So what happens when the Canadi- wanted to go to the States anyway.”

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