Want degree, will travel

Amie Dmytryshyn did everything right. She volunteered to counsel patients at Vancouver General Hospital on Thursday nights. She spent three days a week assisting a quadriplegic teenager. On weekends, she attended intensive all-day MCAT prep and on weeknights she squeezed in two extra hours of studying to prepare for the exam. She did it all while maintaining an A average in her chemistry-heavy human kinetics program at UBC. “Then I got one letter and my dreams were crushed,” says Dmytryshyn, now 30.

Erik Vakil, 28, was so determined to get in that after being rejected from a dozen programs in 2006, he marched straight back to Dalhousie and retook every class in which he didn’t have an A. The following January, he was rejected again. “It was only after the second rejection that I realized I wasn’t going to get in,” says Vakil. A friend suggested he try Ireland. He stayed up late that same night to finish his application. Weeks later, he was called for an interview with the Royal College of Surgeons in Ireland (RCSI).

Considering only one in five of the nearly 11,000 students who apply to medical schools across Canada each year are admitted, Dmytryshyn and Vakil are not alone. Some apply again. Most move on to other careers. But for students who see medicine as a calling, who can’t imagine doing anything else, there are other options. Six years after she got that fateful letter, Dmytryshyn is preparing to take over as chief resident of pediatrics at B.C. Children’s Hospital in her hometown, Vancouver. In August, she married her long-time partner, Byron Hyttenrauch, and the couple are planning a honeymoon in Tahiti. Meanwhile, Vakil is entering his fourth year of med school in Ireland with contacts at the Cleveland Clinic and the Mayo Clinic already in his address book.

It was a gamble, but both students are glad they applied overseas. “Originally, it was Plan B,” says Dmytryshyn, who attended St. George’s University on the Caribbean island of Grenada (pop. 110,000). “But as soon as I got there, I realized that everyone’s there because being a doctor is all they ever wanted to do. Think of the passion that comes from people willing to go halfway around the world to study.”

It certainly takes passion to go to an international medical school. An estimated 1,500 Canadians were studying at foreign medical schools in 2006. While there’s no clear 2010 estimate, medical schools in the big three countries where Canadians study—Australia, Ireland and Grenada—all report triple the number of Canadians just four years later. Admissions aren’t as tough in these countries, but tuition can be jaw-dropping. St. George’s, for example, costs $200,000 for a four-year degree, compared to the $80,000 it costs to attend the University of Toronto. On top of that, most international medical graduates (known as IMGs) are unable to return home for several years after graduation, because—despite a doctor shortage—the number of residencies in Canada is tightly capped. What’s worse, provincial governments and medical schools give first pick of residencies (three to five years of post-graduate training) to Canadian-trained doctors and leave only scraps for the often-discouraged IMGs. This spring, 88 per cent of graduates from Canadian medical schools got their first choice of residency; only 21 per cent of IMGs received a position at all.

Dmytryshyn wasn’t even allowed to apply for the first round of residency placements in her home province of British Columbia. She could have found a spot more easily if she had been willing to sign a “return of service agreement” that says she would work for five years in an area of the government’s choice (usually an isolated northern community) in exchange for a spot. A northern town is not the type of place Dmytryshyn could see herself spending five years, especially considering her husband works in shipping, a field that requires him to live near the ports of Vancouver. She knew her chances weren’t good, but she crossed her fingers and held out hope for a spot near home. “I lost sleep over it, of course,” says Dmytryshyn. “When applying back to Canada after being in school for eight years, you really hope you can be near your family.” Dmytryshyn is one of the lucky ones.

What’s frustrating for many IMGs is that, even with the small chance of getting a spot, the equivalency process can be gruelling. In Quebec, equivalency includes both language tests and the Medical Council of Canada Evaluating Exam (MCCEE), an advanced, $1,500 test that Canadian graduates don’t have to take. Students say the process requires taking a year off after graduation to complete. Even more frustrating for IMGs is the fact that residency spaces reserved for domestically trained doctors sometimes go unfilled without ever being offered to them. Joe Schwarcz, a Ph.D. chemist and head of McGill’s Office for Science and Society, sits on the medical school’s admissions committee. He says it’s a “torturous job” to choose 160 students for first-year medical school each year, because it means rejecting “at least as many equally qualified applicants.” Considering those painful decisions, he wonders why IMGs can’t apply for leftover spots reserved for students at Canadian universities. “These students are getting residencies in the U.S., so why are they good enough for the U.S. but not Canada? It’s crazy,” says Schwarcz.

Melody Ko, 27, dreams of a residency at McGill, where she received her bachelor’s degree, but won’t even bother applying in Quebec because her chances are so low. Ko seems like a good candidate. She’s a multilingual (English, French, Mandarin and Taiwanese) Montrealer who fell in love with Quebec after arriving from Taiwan at the age of 10 and is willing to take family medicine over a specialty. Instead of a residency in La Belle Province, she says she’ll apply to work in New York after graduation from St. George’s, because she doesn’t want to take a year off to pass Quebec’s equivalency requirements for only a small chance at getting a spot. “I feel like I’ve been exiled, to be honest. A lot of us want to go home, but they make it too hard.” Ko considered working in a rural area of Ontario in return for a residency spot (Quebec has no return of service program) but, much like Dmytryshyn, she doesn’t want to “be trapped for five years.”

Schwarcz says he used to believe that Canadian provinces were unwelcoming to Canadians who studied medicine abroad because they perceived the quality of their graduates to be lower. But now that he’s travelled to St. George’s (where he was paid to teach a course), he believes the quality is the same. Schwarcz says the pass rate for the United States Medical Licensing Exam (USMLE) Step 1 should be evidence enough that foreign-trained grads are usually capable doctors. The overall pass rate for graduates from St. George’s was 88 per cent between 2001 and 2008—only slightly lower than the typical pass rate of 92 per cent rate for MD students trained in Canada and the U.S.

That’s not to say that degree mills don’t exist, he says. An American study of graduates from Caribbean schools found students from some countries, like Grenada, did well on the USMLE over a 15-year period, but students from other countries were extremely unprepared. For example, only 19.4 per cent of Saint Lucia’s grads passed the test on their first try, compared to 84 per cent of St. George’s grads during the same time period.

It shouldn’t be a surprise that St. George’s graduates do well on the test, says Ko. They use North American textbooks and, often, North American professors. Ko was taught by several medicine professors visiting from the University of Western Ontario in London, Ont., a school where only six per cent of applicants were admitted in 2007.

But the greatest equalizer, say both Dmytryshyn and Ko, is the final two years of the St. George’s program, called a clerkship, which takes place in U.S. hospitals alongside Ivy League students from Cornell University. The source of Ko’s degree was never an issue in training, though Dmytryshyn can remember one time when a supervisor inquired as to her alma mater. That was after a cardiologist passed around an electrocardiogram print-out and she was the only resident to recognize the rare case of Wolff-Parkinson-White syndrome. “Where did you go to school?” he asked, obviously impressed.

In fact, researchers have studied whether IMGs (both Canadian and immigrant) have different patient outcomes. In a 2005 study of 130,000 heart attack victims treated in Ontario over an eight-year period, those treated by IMGs had identical rates of survival after one month and one year as patients treated by Canadian-trained colleagues.

Plus, international medical schools mean international experience. Dmytryshyn realized this when she started her clerkship at New York Methodist Hospital in Brooklyn. “In the Caribbean we’d serve the local population, who are more than happy to have med students doing breast exams and blood pressure,” she recalls. The Cornell students didn’t appear to have had any such hands-on experience. She also realized that because of different laws, she had gotten more practice with cadavers than her North American colleagues. “The school practically has keys to the morgue,” she says, with a laugh. She also saw more knife and gun wounds than she would have seen at any Canadian hospital—a thrill, she says.

Vakil concurs. He says that experience in international hospitals was the best surprise about studying abroad. RCSI has placed him at hospitals in Ireland, Jordan and across America. Soon he’ll try a South African hospital. “My friends who got into medical school in Canada say they get maybe one chance to study abroad,” says Vakil.

But in some ways, RCSI is more like Dalhousie than Vakil had expected. There was another student from his hometown of Victoria in his first semester, one of 700 fellow Canadians studying medicine in Ireland right now. There are also annual Canadian-themed parties. During the men’s gold medal hockey game at the Vancouver Olympics, Vakil felt especially close to home. Dozens of fellow Canucks packed into a pub near the university in Dublin and clanked pints of Moosehead to celebrate Sidney Crosby’s winning goal.

Although Vakil wants to come home, he says his chances of landing an internal medicine residency in B.C. are so unlikely that, like Ko, he probably won’t even apply. He says Ontario’s return of service agreement program has made it much easier for IMGs to return than it used to be, but it’s not the right choice for him. “Let’s say I bring my girlfriend so I can do a residency in Toronto. That becomes our life. Then after that’s done, if I’m asked to move to Thunder Bay, Ont., for five years, do I leave my girlfriend behind?” asks Vakil. On top of that, Vakil plans to be an internist and IMGs have more trouble getting into specialty programs like internal medicine, where the competition is fierce. He says he’s resolved himself to working in the U.S. where he’s already made contacts.

It’s Canada’s loss. Vakil says he’d much rather work in the Canadian medical system because it’s a system he supports. But as he prepares for a minimum of five years of training in the U.S., it’s difficult for him to say when, if ever, he’ll return to Canada.

That’s a shame, but it’s nothing new, says Ah Yin Eng, the head of the Association of International Physicians of Canada and a veteran GP in Pembroke, Ont. “Governments complain of a medical brain drain,” says Eng. “But with IMGs, year after year, we lose them to the States.” In the case of Quebec, Health Minister Yves Bolduc says that while the doctor shortage is a problem, he has no fears that Quebec is losing doctors to the U.S. “I think we will have enough family doctors in four or five years,” says Bolduc, who says equivalency processes and allotment of spots are fair. Eng says there’s another reason health ministers aren’t accommodating IMGs who want to come home. “I think they have a hidden agenda,” says Eng. “In Ontario, they’re trying to use nurses and pharmacists to replace doctors. They’re hoping to save money that way, but it won’t work.” With both doctors and patients aging, Canadians are going to demand more doctors, says Eng. In other words, it’s only a matter of time before they try to lure IMGs back from the U.S.

In the meantime, the increasing number of ambitious young Canadians studying medicine abroad can only hope he’s right. Dmytryshyn says she will encourage applicants who don’t get into Canadians schools to apply for training abroad like she did. Being a doctor has been as rewarding as she expected. One recent patient reminded her why she had worked so hard. A 10-year-old boy who had spent much of his life on dialysis recently received a kidney transplant. “When he came to from surgery, he was able to pass urine for the first time,” says Dmytryshyn. She saw the look of amazement and relief at the yellow liquid he’d produced. He cried. “It’s amazing to see someone so happy just to do something we all take for granted every day.” On days like that, she’s glad she didn’t take getting into a Canadian med school for granted.

Top five destinations for Canadians studying medicine abroad

Ireland: Roughly 700 Canadians are currently studying at Ireland’s six medical schools, including the prestigious Trinity College and the Royal College of Surgeons in Ireland.

Grenada: Canadian students—over 620 of them this fall—get to snorkel, sail and barbeque lobster on the beach after exams. The first two years of their program are spent on the island, where students help out at local medical clinics. The second two years are spent at hospitals in the U.S.

Australia: There are 232 Canadians at several Australian medical schools.
Students who hold a bachelor’s degree from Canada usually take a four-year graduate program with clinical experience mixed in with coursework throughout the entire four years.
Poland: There were roughly 61 Canadians studying at Poland’s seven English-language medical schools in 2006.

Netherlands Antilles: Dozens of Canadians study medicine at six campuses spread out across the three former Dutch dependencies of Aruba, Bonaire and Curaçao, just north of Venezuela.

Sources: Peter Nealon of Atlantic Bridge, Bob Ryan of St. George’s, the Australian Trade Commission, Sandra Banner in CMAJ (2007)