Malcolm M. MacFarlane is a retired psychotherapist, and a volunteer with the Society for Canadians Studying Medicine Abroad
In March, the Canadian Medical Association released its first policy on equity and diversity in medicine. This policy advocates “opening the conversation to include the voices and knowledge of those who have historically been under-represented and or marginalized.” It supports “reduc[ing] the structural barriers faced by those who want to enter the medical profession.”
This policy is encouraging for International Medical Graduates (IMGs). IMGs comprise an ethnically diverse group and many experience marginalization in the Canadian Residency Matching Service (CaRMS) process. To apply to CaRMS, all IMGs must be Canadian citizens or permanent residents, no different from Canadian Medical Graduates (CMGs). They should be entitled to be treated equally to CMGs. They are not.
The CaRMS eligibility criteria set by the provincial faculties of medicine and the provincial Ministries of Health streams IMGs to a limited number of residency positions. This is consistent with a 2006 resolution by the Association of Faculties of Medicine of Canada and accepted by the provincial faculties of medicine that “all graduates of Canadian medical schools be assured access to a residency position in Canada.” The justification often given for this resolution is that CMGs’ undergraduate medical education has been subsidized by taxpayer dollars, and that this investment would be wasted if CMGs didn’t progress to residency training.
IMGs clearly face discrimination in the CaRMS Match. In the 2020 Match, there were 3,072 positions for 3,011 CMG applicants and 60 US medical graduates (USMGs). In contrast, there were only 325 IMG positions available for 1,822 IMG applicants. The positions available to IMGs are limited mostly to family medicine, internal medicine, psychiatry, and a few positions in pediatrics, while CMGs can apply to the full range of specialties. IMGs are also required to demonstrate their competence to practice medicine by passing the MCCQE1 and the NAC OSCE examinations before they can apply via CaRMS. CMGs are not required to sit the MCCQE1 until after the Match is completed and can proceed to residency even if unsuccessful. According to the Medical Council of Canada, about 3% to 5% of CMGs fail this exam each year. Yet IMGs have demonstrated competence through objective assessments prior to applying to CaRMS. If the goal of the CaRMS Match is to select the most competent medical graduates to progress to post graduate medical education, then why are IMGs who have objectively demonstrated their competence not permitted to compete equally for all positions?
The economic justification offered for these different application streams is the protection of taxpayer investment in CMG undergraduate medical education. Taxpayers fund education that leads to various professional degrees, but discussions of taxpayer investment or efforts to protect these graduates do not generally arise outside of medicine. One might argue that this is because education is an investment in society, not an investment in specific individuals. Best business practice and the best interests of taxpayers is arguably to advance the most qualified candidates through competition on the basis of the competence of the individual. Economists call the desire to protect money already spent without analyzing quality or ultimate productivity the “sunk cost fallacy,” and they consider it poor practice.
The objectives of the current CaRMS eligibility process are in conflict: selecting the most competent applicants to progress to post graduate training versus protecting those educated in Canadian and American medical schools. And the issue is not discussed openly and transparently with input from all stakeholders, despite public interest in the issue. Instead, the decision to prioritize CMG access to residency is being made by the provincial faculties of medicine, who would seem to be in a clear conflict of interest advocating for their own graduates. Prior to 1993, which marked the end of rotating internships, the provincial Medical Colleges had responsibility for setting eligibility criteria for residency and entry to practice. Perhaps it is time for these Colleges, who are mandated to regulate in the public interest, to reclaim their authority over this process.
The CMA Policy on equity and diversity in medicine invites a transparent and public dialogue about the CaRMS process for IMGs. A more open dialogue would solicit public input regarding the conflicting public interest objectives described. It might examine the impact on IMGs – many of whom are also Canadian – of being unmatched. It could explore the public cost of underutilizing 1,400 competent unmatched IMG applicants when there are five million Canadians without a family physician. It might look at how the current CaRMS process aligns with Canadian immigration policies, how it intersects with policies and objectives regarding international labour mobility, how current CaRMS policies fit with established principles for recognition of international credentials, and whether the policy contravenes human rights and the Canadian Charter of Rights. There is much to discuss.