Picture of Trevor BruenTrevor 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.