I wanted to respond to this column by The Globe and Mail health columnist André Picard last week—a bit off topic for my blog but not for me personally, as will become clear. 

My son is a pediatrician. He graduated from St. George’s University School of Medicine in Grenada. There are many stereotypes about doctors coming out of Caribbean schools being less qualified than those trained in Canada. They are false. All doctors working in Canada must demonstrate the same capacity by passing stiff exams at each of four stages: entrance into medical school, entrance into residency, entrance into the profession, and board certification.

A candidate who fails at any one of these stages may not go onto the next and may therefore not qualify to practice medicine in Canada. Candidates who were educated, trained, and have worked in countries where the medical system is significantly different than our own must undergo rigorous education and training to practice up to the standards that make Canada’s medical system globally enviable. But in terms of qualifications, these candidates are not the same as candidates who were educated and trained in systems that may operate on a slightly different model but produce physicians that are equally as qualified as those who attend Canadian medical schools.

I can’t speak to medical schools in England, Ireland, and Australia, where the quality of medical care is similar to ours in Canada. I can only speak to what I know about as a result of the fact that my son attended a Caribbean school, a school that has overcome significant prejudice to become a prestigious medical school in its own right.

So, what’s the educational difference for physicians who graduate from a medical school in Canada or one in the Caribbean?* 

First, it’s important to note that medical schools operating in the Caribbean are, for all intents and purposes, USian schools. Students do their first two years at campuses in the West Indies, where the cost of building, operating, and maintaining a medical school is lower than in the US or Canada. They then go onto internships, their first shot at hands-on practice under the strict guidance of experienced physicians, at USian hospitals, where the standards of care are very similar to our standards in Canada.

So, what’s the difference that gets students from basic sciences through internships to graduation and residencies (the second stage of hands-on practice)? It’s basically that Canadian and Caribbean schools use a different operating model, as do medical schools that operate within the geographical US.

In Canada and the geographical US, a student’s credentials for admission to medical school must be the crème de la crème of each year’s pool of applicants. But as Canadian and US-based medical schools operate on a pass-fail basis, once a candidate has been accepted, it’s unusual for them to flunk out. 

And the overall credentials for any pool of applicants are influenced by more than quality. For example, the makeup of a particular graduating class might be heavily influenced by economic conditions at the time they applied. This was the case, for example, during the 2008 recession, when jobs were so scarce that people in many fields were accepting positions well below their qualifications and at lesser pay than they might have been offered months earlier (I knew some of them). 

At that time, many young people went back to school to improve their qualifications. (I was working in international education at the time and had direct knowledge of this.) Suddenly, for reasons having nothing to do with their qualifications, the pools of candidates increased, and many applicants didn’t make it into schools that might have accepted them just months earlier. 

I don’t know if Caribbean schools experienced a bumper crop of applicants at that time, but it would make sense that they did because of their operating model. To gain entrance, one must pass the same rigorous exam as is the basic requirement for all students, but other entrance qualifications may not be as stringent. For example, a student might have just barely passed their exam, might have less volunteer experience in their application, or might not have done as well in the interview. 

Does that mean students graduating from these schools are less qualified than those graduating from Canadian schools? Not at all. Caribbean schools operate on a model that accepts students from around the world whose entrance qualifications may be lower than required by Canadian schools. But then, unlike in Canadian schools where it’s near-impossible to flunk out, their progress is graded at every turn.

This gives the students an opportunity to improve on any deficiencies in their entrance requirements and repeatedly show that they deserve their spot in the school. It also contributes to a very high attrition rate, which can top out at around 60%.

This is not cheap for students. At the time my son completed his education, the cost was $400,000 USD, easily four times higher than a Canadian school. And students who flunk out don’t get a refund on what they’ve paid for their year.

The most-qualified applicants are offered significant scholarships to encourage them to attend. However, given the schools’ global focus, the largest scholarships typically go to students from majority world** countries who couldn’t otherwise afford to attend but who will take their education back to their home countries to improve life there—a fair system if I’ve ever heard of one. 

After finishing their two years of basic sciences, students complete their internships at hospitals in the US. In contrast to students who attend Canadian or US-based schools, this gives them an opportunity to do part of their internships at different hospitals, working under different doctors and different systems and exposing them to a wide range of perspectives, which I see as a bonus to this system.

In other words, students who make it through the rigorous program of studies at Caribbean-based schools are at least as qualified as students who attend school at a Canadian or US-based medical school, if not in some ways more so.

Yet the column I linked to at the beginning of this post was titled “International med school graduates are an untapped resource, as well as a complex challenge.” In it, Picard writes:

“It’s important to note that there are two types of IMGs. The first are Canadians who study medicine abroad in places like Grenada, Ireland and Australia, usually because they weren’t accepted to Canadian schools. They argue they have a “constitutional right” to compete for residency spots on an equal footing with Canadian grads if they pass Canadian exams.

“The second type of IMGs are those educated in other countries who emigrate to Canada. If they do so before residency, they have little chance of getting a spot. (The exception is grads from countries like Saudi Arabia, who “buy” residency spots but must return home after training – a topic for another day.)

“We limit the number of doctors we train because money isn’t unlimited. We already have 97,384 physicians in Canada, and spend $32.5-billion annually paying them. Rationing is a reality.

“If we want more doctors, then one avenue is to open more residency spots for IMGs. A report last year from a group of independent senators recommended adding 750 spots, essentially doubling the current number.

“Of the group of IMGs who have trained and worked in other countries before emigrating to Canada, some of them could start work tomorrow while others do not have the appropriate qualifications. The challenge for regulators is to figure out who’s who.

“The path to practice has many hurdles: demonstrating you graduated from a legitimate medical school, having your credentials verified, passing Canadian exams, showing competency in English, having your competency tested and finding a job.”

I agree that ensuring the IMGs who lived, trained, and worked in other countries before coming to Canada must be carefully vetted before working as physicians in Canada, and doing so can be complicated. But when it comes to Canadian students who simply went overseas to train in systems that operate on a slightly different model but graduate physicians who are equally as qualified as those who study at Canadian schools, as demonstrated by the rigorous screening they must go through before practising in Canada, I fail to see the challenge. As the first link in the above quote (to SOCASMA, the Society of Canadians Studying Medicine Abroad) notes:

“Currently, provincial Ministries of Health allow Canadian medical schools to control selection for entry level training jobs called medical residencies. Canadian medical schools have used this power to exclude qualified Canadians from competing against their graduates for these positions.

“Canadians who have studied medicine anywhere but Canada and the U.S.A. are prohibited from competing against their peers who graduated from Canadian and American medical schools. They can only compete in the IMG (international medical graduate) stream, and only if they agree to enter into return of service contracts. The IMG stream is a very limited opportunity stream.

“In British Columbia, only 4 out of 65 medical disciplines are available to Canadians who have international medical degrees despite passing the national medical knowledge and clinical skills exams.

“Canadians, who choose to study overseas, and other international medical graduates, are treated as second class citizens when it comes to competing for positions in one of the most prestigious callings in Canada. The two-class system of medical residency selection currently in place is an affront to the fabric of Canadian society. This type of class system feeds the growth of a culture of entitlement and it feeds prejudice, both of which are destructive to a free and democratic society. It also prevents Canada from hiring the most qualified Canadian physicians. This impacts access to health care and the quality of health care for all Canadians.”

The blocks to this stream of IMGs practising in Canada are, to avoid mincing words, stupid. At a time when 6.5 million Canadians lack access to a physician, the rules and regulations that categorize Canadian graduates of fully accredited medical schools abroad along with physicians who graduated from medical schools that cannot hold their own in the Canadian system are, not to put too fine a point on it, stupid. 

I fully understand and agree with the need to ensure physicians practising in Canada are qualified to practice at a level commensurate with our own graduates. But the existing system miscategorizes graduates of a system where the only differences are that a) Canadian students study outside our borders, b) students who under perform can flunk out at any stage of the game, and c) students pay for the full cost of their education themselves rather than having it subsidized by Canadian taxpayers. 

This creates disadvantages that affect all of us. It needs to change. 6.5 million Canadians who don’t have a physician of their own can’t afford for it not to change. 

(*There may be other differences between schools in Canada and other countries, such as Ireland or the UK. For example, some countries do not require doctors to complete an undergraduate degree before applying to medical school, as we do in Canada, but admit students directly from secondary school into a pre-med program and from there into medical school.)

(**I prefer the terms majority world and minority world countries to value-laden terms like first world and third world or developed/industrial world and developing world. Majority and minority world reflect the reality that the world’s wealth is concentrated in the pockets of the minority populations of a few countries, while the majority of the world lives in poverty that most of us in countries like Canada and US can’t even imagine. I like the way these terms, which I first encountered in a magazine called The New Internationalist and which I highly recommend, force people to stop and think about what’s really going on in the world.)