Trevor Bruen is a PGY-1 in Family Medicine (R1 EMNO, médecine de famille) at the Northern Ontario School of Medicine.
I had transitioned from working as an assistant professor, teaching mathematics and statistics, to receiving a Canadian medical school acceptance within two short years of returning to full-time studies with community engagement. There was one slight caveat: my offer was to a French-speaking medical school. My concern over language made my decision to accept the medical school offer difficult – even though any acceptance to a Canadian medical school is usually a reason to celebrate.
My closest confidants made light of the language factor and strongly encouraged me to accept the offer. Since I was not from Quebec, I was unwisely reassured by my belief that my limited knowledge of French had been duly considered by the program – after all, I had stumbled through a French-language multiple mini interview. But I later recognized that more rigorous assessment of communication and linguistic capacity only became integral admission requirements in the years following my matriculation. Nevertheless, at the time of my decision, my financial situation was precarious so starting medical school seemed like a logical decision as funding for medical studies would be available. I realized that even supposing excellent interview chances the following year, my financial resources for another year of undergraduate studies would have been very limited. So, I decided to accept the medical school offer and immediately sought some aid to improve my knowledge of French.
From my first tutorial, however, a tutor noted a substantial « barrière linguistique » which sadly persisted until the end of my program – over the years, I improved but not enough to excel. In a couple of months, I had gone from teaching small groups of eager pre-medical students to prepare them for the MCAT to struggling to follow introductory seminars. The language barrier that I now faced was a recipe for academic challenges. Despite my extraordinary scholastic effort, I had to repeat my first-year and I lost much of my tenuous social network. Even though I passed all but one block, I was a hair’s breadth away from being excluded from medical school due to my academic standing – quite a reversal from my lifetime career as a researcher and scholar.
It felt as though I had unwittingly begun an adult immigration experience where my future livelihood and success depended on nearly instantaneously adapting to a new culture and language. As a colleague with a similar experience aptly noted, “I learn less effectively in French.” The option of transferring to another Canadian medical school was not available to me. However, I worked continuously on improving my French and my medical knowledge despite the obstacles. Learning was a blur of arduously attempting to work around the language barrier, often translating to and from French with the help of technology like Google Translate, while trying to understand medical concepts. I later learned that working memory, which is crucial for lengthy reviews and charting, as well as academic performance, can significantly decrease in a second language environment.
My clerkship (practical training) eventually began, in early 2019, with pre-pandemic visiting electives that were the highlight of my medical school years. While early electives are considered disadvantageous to most clerks, to me they represented an opportunity to train in English. Not only did I receive excellent to stellar evaluations, I had the opportunity to briefly touch base with some friends and family in Calgary, Montreal and Toronto. It was gratifying to receive positive feedback and to believe that a bright future may lie ahead – elective performance is usually the most important factor for interviews and matching within CaRMS.
Unfortunately, when I returned to my medical school, the excellence that I had demonstrated during away electives was more than nullified by the difficulty of adapting to the French-speaking hospital environment. I had mistakenly thought that language would no longer be an issue after so many years of pre-clerkship; however, I realized that language was still a barrier for rotations that depended on extensive communication.
I was encouraged to apply to CaRMS, but I went unmatched through both rounds which was a devastating experience to me. Programs that I had rotated through as an elective student extended no interview offers, even in one location where a senior staff and residents had openly discussed the likelihood of a future interview. My hope in the future that I had imagined, that had sustained me through difficult moments, was briefly shattered. However, I appreciated the kind support of some francophone medical staff who shared their own challenges during English-language training.
Subsequently, I had the opportunity to remediate a few rotations where the language barrier had been most problematic. After a lengthy immersion in a French-speaking clerkship, and my continuous studying, I was able to perform substantially better. Some staff were even happy to provide strong references.
I also had an opportunity to complete an elective block that had been postponed due to the COVID-19 pandemic. These final rotations in English-speaking environments allowed me to demonstrate my capacity to attain the highest levels of performance as a senior medical clerk in competitive disciplines. I found that expanding my medical knowledge, as objectively demonstrated by an above-average MCCQE Part 1 result, for instance, was considerably easier than achieving my full potential in a French-speaking medical environment.
While CaRMS is officially and visibly bilingual, there are barriers to matching between English- and French- speaking medical schools that extend beyond language. Notably, there are different research traditions and other cultural distinctions with respect to student evaluation and support. Additional electives for unmatched students, for example, are not offered in French-speaking medical schools. While many English-speaking schools have extensive research and other opportunities that allow medical students to distinguish themselves for matching purposes, French-speaking schools have traditionally relied more extensively on letter grading to separate students (however, French-speaking schools have also now adopted pass/fail grading). Matching across linguistic divides between Quebec and the rest of Canada has therefore occurred somewhat sporadically.
When I re-applied through CaRMS the year after I did not match, a helpful note was eventually added to the front page of the Dean’s letter, which mentioned my linguistic adversity. Though my language issues were noted to various degrees in my evaluations, having a senior administrator acknowledge language as a factor in my overall record was likely crucial in my securing interviews in the second round. My own explanations, given in the first round, may have been simply dismissed as excuses – I had naively believed that the practical challenges of bilingualism, which also lie at the core of our national identity, would have merited some additional consideration.
As I I applied broadly through both rounds of CaRMS in 2020-21, I realized that there is a degree of bureaucratic blindness with respect to the process. Outright exclusion is easier than case-by-case consideration. While the process allowed for an applicant’s lack of elective exposure to disciplines due to pandemic restrictions, any performance impediment resulting from my imperfect bilingualism was unlikely to have been considered. I was simply a ‘flagged’ applicant – unworthy of serious consideration. Nonetheless, although I never received any interviews in the disciplines in which I demonstrated the greatest aptitude and interest, I received other interview offers and was pleased with my program match.
I believe that my experience overcoming cultural and linguistic adversity will help me better care for patients in the context of their respective hardships. And I had the chance to better comprehend my own heritage: the immigration challenges that my maternal grandparents faced after their courageous wartime escape across the Gulf of Finland. They had needed to exchange prosperity for autonomy and survival – their daily challenges of adapting to a vastly different life and language in their adopted country must have been very arduous indeed. I developed some insight into the invisible struggle of adult immigration, including isolation and loss of agency, through my own ordeals and the broad sacrifices it often entails. Often, the value of such sacrifices is only seen much later – even in future generations. Yet, I sometimes wonder whether my own challenges will ever represent anything more than lost years which made it very difficult to achieve my fullest personal and professional potential at a critical juncture.
Thank you for sharing your experience. It must feel so frustrating to face so many hurdles in your training. I have to say though, it is wonderful to know that you have been able to cultivate such persistence through all of this. I am sure this is a character that will make you the one of the best in your field.
This story of the challenges of navigating in something other than one’s first language should remind us of the importance of communication in medicine. This is true from the patients’ perspective as well as the physicians. This is why our current system which prevents IMGs who meet the Canadian standard and are qualified to work as resident physicians from applying for 90% of the positions in Canada is harmful. Our country is one comprised largely of immigrants and yet our system unapologetically excludes from access to licensure most immigrant physicians and prevents them from serving immigrant patients with cultural sensitivity in their first language.
Thanks for you comment and perspective. I certainly agree that cultural sensitivity and communication is of vital importance in medicine. Unfortunately, I think the comments regarding IMGs goes well beyond the scope of my article.
A friend forwarded your blogue to me and even though I am not a physician, I felt compelled to respond and to contribute to this discussion. I totally understand your struggles learning another languages at the same time as you were going through medical school. Let me explain. I am a Franco-Ontarian from Northern Ontario. I was raised in an entirely French speaking community and did all of my studies in French (except for the required English courses) until the time I started working for the federal government in Ottawa in my early thirties. Thank goodness I had a boss who was patient and a good coach because it was a real struggle working at times in French and at other times, in English. Not only was I perfecting my knowledge of the English language, I was also getting acquainted with a culture that was largely unfamiliar to me, all the while trying to do my job in the very complex federal government environment Throughout my entire 30 years career in the federal public service I had to make sure that I did not neglect one language for the other. It was hard work, something most people who are not bilingual do not understand. While I appreciate the struggles you have gone through to become bilingual while going through school, I hope you one day get to the point where you can simply enjoy knowing French. Interact with francophones (including your patients), attend plays, listen to French music, get acquainted with French Canadians’ culture, travel in Quebec, France, Martinique, Guadeloupe and other francophone countries. Basically, just have fun, enjoy learning and expand your horizons. That’s what learning English has given me and I am forever thankful.
But there’s one element of your letter that left me puzzled. I am still very involved and knowledgeable of Northern Ontario as I am now retired and spend a lot of times at my cottage in the North. I’ve always known that NOSM is not a francophone program. It’s an English one with an openess to French same it strives to show an openess to the North’s aboriginal community. And that’s how it’s stated on NOSM’s web site : https://www.nosm.ca/our-community/francophone-engagement/ With this in mind, can you explain to me why French was such an issue for you? I can appreciate that a few work environments during your clerkships would involve some and possibly a fair amount of French (especially in communities such as West Nipissing, Kapusking, Hearst and to some degree, Sudbury). But the vast majority does not, and in fact most Franco-Ontarians are very accomodating and will readily speak English if required. What am I missing? (For readers who are not family with the linguistic landscape of Northern Ontario, let me just say that approximately 30% of the population speaks French, with some communities being very French, others very English and yet others, very bilingual.)
But you are right in saying that there is very little understanding and appreciation of the challenges one faces learning and functioning in both English and French. While there are some attempts to meet the needs of francophone patients, the current medical school recruitment system hardly recognizes the fact that the bar is much higher for medical students and residents trying to not only meet the basic requirements of their second language, but also striving to function at the highest level whenever required, all the while going through the enormous amount of information one needs to absord in medical school. I say this because my own daughter, who is now a physician, did medical school in English after having gone through primary school, secondary school and her undergrad all in French. Is the system perfect? Absolutely not. Can it do better? Most likely. But at the end of the day I can say without a doubt, that francophone patients in Ontario and across the country are very appreciate of any physician who shows openess to the fact that they are French. Making an effort and showing an openess to our language and reality, is a clear door opener to good communications between a physician and the patient. It can resolve a lot of misunderstanding and in the end, give you much better results. Bonne chance dans ta carrière et merci pour ta persistance et ta contribution!
Thank you for very much for your thoughtful reflections and sharing your own experiences. Yes, I absolutely believe that acquired bilingualism, especially later in life, can require significant effort. Like you say, the challenges of multi-lingualism are not always obvious – and there are usually degrees of comfort in any given language.
Yes- I am glad to be able to serve francophone patients in their language throughout Canada and in Northern Ontario where I am presently. I do agree language is a bridge to understanding. I must mention that I have already been impressed by the bilingualism of numerous franco-Ontarions who are able to speak both languages with seemingly perfect fluency!
And finally I am sorry for the confusion in my article. I trained in Québec (Sherbrooke), but am doing my residency at Northern Ontario School of Medicine, which as you mention does have a mission to serve franco-Ontarions.
Je vous remercie pour vos aimables paroles!
It might surprise you to know that today many Canadians and permanent residents face even tougher discrimination on the basis they study medicine outside of Canada. So while you faced difficulties, you were able to apply in the first round of CaRMS and apply to any disciplines. Canadian citizens who studied abroad and who have taken exams to establish Canadian competence are barred from the first round of CaRMS and can apply only to very limited specialities in the second round. I applaud your achievement but I don’t think it can truly be compared to the immigrant experience or to the experience of Canadians who study abroad. I think they would say you had it pretty easy by comparison. . In addition to Canadian citizens born and educated in Canada who are discriminated against because they studied abroad- there are today also immigrants to Canada who cannot use their medical expertise because they were educated elsewhere. Despite passing Canadian competency exams. That this is still a fact should make us all feel ashamed.
Thank you for your comment and sharing your perspective. Every experience is unique and individual. It may surprise you that I have Canadian-born IMG colleagues who have kindly expressed that they actually felt that my experience seemed even more challenging than their own and expressed their admiration for my achievements.
But, I certainly have also met other IMGs who have immigrated to Canada in the hopes of pursuing their career in medicine but have found adapting to culture and language to be very challenging. If you read the article carefully, you may have note that many of my interviews in CaRMS were for positions that were open to IMGs as well. Unfortunately, I do feel much of your comment is outside the intended scope of the article.