Canada vs. US for Residency?

[tmtvt]

Somewhat specific question but hoping to get some thoughts on the situation.

I'm a MS4 at a med school here in the US I'm planning on applying to a surg specialty for residency. I'm taking a research year currently but will be submitting an ERAS (+/- Carms) app in 2024. I decided to do med school here in the US as I'd been living here for awhile (undergrad in US) and thought it made the most sense to continue my med ed here state side to make the most out of it. I made the mistake of choosing prestige over the practical path toward my end goals and it's coming back to bite me.

In retrospect, I should've applied to med schools in Canada, just to give me the option of going back, but here we are. Don't get me wrong, I've really enjoyed my medical education for the most part in the US (and I apologize if I come off as an ungrateful jerk), but I've come to realize that I don't see myself practicing in the US medical system long term.

The issue is, the job markets for my specialty here vs. Canada couldn't be more different. The job market for my specialty in the US is far stronger than it is in Canada (many Canadian residents / fellows end up having to move to the US to avoid having to get a masters/PhD, multiple fellowships in the field just to get a job). If it were even somewhat close, I wouldn't mind taking the risk and just heading back home, but the differences in job outcomes are so stark it would be stupid not to consider them.

I'm really struggling with what I should do. If I complete my training here in the US (which I don't necessarily mind doing, although I would slightly prefer to do it back home), I feel like I've lost out on the implicit/explicit networking that takes place and is essential for landing a job back home in Canada. If I were to go back home to train in Canada, I could very likely be in a position where I wouldn't be able to land a full-time job (not necessarily even in the province I'm training in, but in the country as a whole) without going down the MSc/PhD or multiple fellowship path). Also, many of the US-based positions that Canadian residents end up landing tend to be somewhat less desirable than what would be attainable if I were to train at a middle of the road program here in the US. I don't really have anyone to turn to since I haven't ever really heard of any Canadian moving back to the US after completing residency training here. Practically, the path is clear from the Royal College and there aren't too many hurdles to getting certified in Canada after a US residency. But, given how tight the job market is back home, I'm not sure if I'd even be able to land a job interview as someone who trained out of the country.

I plan on applying to both match processes, but the issue is the fact that they are linked. Usually (pre-COVID), Canadian match (Carms) was always before NRMP match, and they are linked. If you match in one process, you are automatically pulled out of the other, without ever seeing / knowing the outcome of that second process, and its based on match timing (i.e. which one comes first takes precedence). This would have been fine for me since I could apply to both, rank my top Canadian choices that I would take above any US position, and then see what happened. For the last two years, the timing has switched, and now Carms match comes after NRMP match week, meaning that I would have to completely forego my NRMP match just to see if I'm able to even to land a spot in Canada (and potentially risk it all and not match in Canada?)

Should I just apply for both and see what happens throughout the interview process in both countries and make a decision from there? Resign myself to having to complete training here in the US unless I'm fine taking a second gap year if I don't match in Canada the first time around? A compromise I've been thinking of is doing residency here in the US, completing fellowship in Canada, and then hopefully taking that route to returning home?

Any advice would be greatly appreciated! On the off chance there are any Canadian surgeons that returned home after training here in the US, would love to know what that looked like!

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[VisionaryTics]

I'm a US citizen who practices in the US but did fellowship in Canada and have some insight into job market on both sides of border (at least in my field, which sounds similar to what you've heard).

Canadian surgical subspeciality jobs are few and far between. In my field, the country trains about 10 fellowship-trained surgeons and a spot opens up for a faculty position once every 2-3 years across the whole country. Most of the fellowship-trained Canadian surgeons who stayed in Canada go into general practice. The ones that got the highly sought off academic jobs, as you said, were highly networked. Some associate or full professor physicians came from US after building very strong resumes there, but junior faculty starting in Canada were heavily connected, and often had PhD or masters. Those who didn't have advanced research degrees were required to obtain them early in academic practice.

As a result, a lot of Canadians look to the US for jobs. For those who did residency in Canada, there are usually stricter requirements for practice (e.g. need to be sponsored by an academic institution in US before getting independent practice privileges).

If your #1 goal is returning to Canada for practice, I think doing Canadian residency is the best option. You said "Practically, the path is clear from the Royal College and there aren't too many hurdles to getting certified in Canada after a US residency", but I don't agree with this. The certification process requires being sponsored by an academic institution, and like I said those jobs are few and far between. In addition, the credentialing process can still take years, i.e. you finish US residency, and it takes CPSO (or whatever provincial organization) over a year to even grant a certificate for practice while they "investigate" your training. My wife, as a result, still lived and worked in US as a physician while I was in Canada because it would've been impossible for her to get a job within the few years I was there training.

So all being said, it is way easier for you to stay in Canada if you are trained in Canada. But just be aware the job market is much worse off than the US, and many Canadians will pursue American fellowships as a springboard to American jobs.

 

[tmtvt]

I'm a US citizen who practices in the US but did fellowship in Canada and have some insight into job market on both sides of border (at least in my field, which sounds similar to what you've heard).

Canadian surgical subspeciality jobs are few and far between. In my field, the country trains about 10 fellowship-trained surgeons and a spot opens up for a faculty position once every 2-3 years across the whole country. Most of the fellowship-trained Canadian surgeons who stayed in Canada go into general practice. The ones that got the highly sought off academic jobs, as you said, were highly networked. Some associate or full professor physicians came from US after building very strong resumes there, but junior faculty starting in Canada were heavily connected, and often had PhD or masters. Those who didn't have advanced research degrees were required to obtain them early in academic practice.

As a result, a lot of Canadians look to the US for jobs. For those who did residency in Canada, there are usually stricter requirements for practice (e.g. need to be sponsored by an academic institution in US before getting independent practice privileges).

If your #1 goal is returning to Canada for practice, I think doing Canadian residency is the best option. You said "Practically, the path is clear from the Royal College and there aren't too many hurdles to getting certified in Canada after a US residency", but I don't agree with this. The certification process requires being sponsored by an academic institution, and like I said those jobs are few and far between. In addition, the credentialing process can still take years, i.e. you finish US residency, and it takes CPSO (or whatever provincial organization) over a year to even grant a certificate for practice while they "investigate" your training. My wife, as a result, still lived and worked in US as a physician while I was in Canada because it would've been impossible for her to get a job within the few years I was there training.

So all being said, it is way easier for you to stay in Canada if you are trained in Canada. But just be aware the job market is much worse off than the US, and many Canadians will pursue American fellowships as a springboard to American jobs.

Seriously appreciate this response, this is helpful. If you were in my shoes, how would you go about approaching the match. If I try to match into a Canadian spot, I'd have to forgo the US match entirely (which after a full research year here seems like kind of a waste, but it is what it is). I also worry that I wouldn't have any of the "informal" assurances in the Canadian match that are way more common here in the US that can help guide that decision (e.g. rank to match calls / emails, having home dept confirm that they'll take you). I don't mind sitting out the US match entirely but I guess I'd want some sort of hedge against the risk of not matching in Canada. I guess I could maybe spend that second "gap year" getting a Masters to help with job stuff down the line if I don't match? Seems like kind of a rough opportunity cost to take but I'll stomach it if I have to.

Also again more of a hypothetical question, and I'm not sure there's a definitive answer to this without asking the people directly involved, but how do you think dual applying (across countries) would look with respect to the home program. My school and home program very academic medicine-focused and I think I would have a decent chance of matching at my home program (according to some mentors here) if I were to apply with my app currently. I don't really want to stay at my home program (more for location reasons), but I would kind of be worried that they'd be less willing to go to bat for me for making calls to other US-based programs I'm gunning for (or have any sort of reasonable pull at Canadian programs) if they knew I was applying in the Canadian match as well (maybe shows I'm less dedicated to the kind of high power academic-medicine type of medicine that takes precedence here vs. the still very academic, but less research geared residency programs at home?). I'm really hesitant to bring up this topic with mentors just based on the explicit / implicit bias it could have when I go through my app cycle in a year.

 

[Medstart108]

Are you sure the Canadian match would happen second now? I know it has been like that for pandemic but heard rumors things were switching back. The Canadian system does not like it when the Canadian match happens second because it leads to brain drain. In the last two years there was a trend for Canadian medical students to match to top tier US programs.

Either how, as a Canadian who is actually seriously considering/preferring the US for practice, i'm curious why you don't like the US system?

I agree that doing residency where you want to practice is essential and residency is where you set down roots. You will be hard pressed to get a Canadian job in surgery without either the local connections developed during residency or serious pedigree (talking big names only).

I think your life will be infinitely easier if you just did your residency in the US and aimed to practice in the US personally. If you absolutely must maximize your chances in Canada, then aim to do your residency in Canada, but its risky the whole way through, you'll have to take some degree of risk applying to Canada from a US medical school and then you'll kind of have a foot in both countries but nothing locking you in at either.

Another important factor is where in Canada you want to work, if you are flexible to any job in Canada, its more reasonable, but if you are thinking the big cities like Toronto/Vancouver/Montreal, the door is narrow for you to come back. The only exception is that surgical residencies in programs like Toronto will open doors for Canadians coming in from Ivy league or equivalent med schools, otherwise they almost always prefer Canadian applicants.

 

[tmtvt]

Are you sure the Canadian match would happen second now? I know it has been like that for pandemic but heard rumors things were switching back. The Canadian system does not like it when the Canadian match happens second because it leads to brain drain. In the last two years there was a trend for Canadian medical students to match to top tier US programs.

Either how, as a Canadian who is actually seriously considering/preferring the US for practice, i'm curious why you don't like the US system?

I agree that doing residency where you want to practice is essential and residency is where you set down roots. You will be hard pressed to get a Canadian job in surgery without either the local connections developed during residency or serious pedigree (talking big names only).

I think your life will be infinitely easier if you just did your residency in the US and aimed to practice in the US personally. If you absolutely must maximize your chances in Canada, then aim to do your residency in Canada, but its risky the whole way through, you'll have to take some degree of risk applying to Canada from a US medical school and then you'll kind of have a foot in both countries but nothing locking you in at either.

Another important factor is where in Canada you want to work, if you are flexible to any job in Canada, its more reasonable, but if you are thinking the big cities like Toronto/Vancouver/Montreal, the door is narrow for you to come back. The only exception is that surgical residencies in programs like Toronto will open doors for Canadians coming in from Ivy league or equivalent med schools, otherwise they almost always prefer Canadian applicants.

Appreciate the response! As of this app year (2022-2023), the matches are still scheduled to be in the reverse format (Carms second NRMP first, the difference is a week or so). I've noticed that Carms has also pushed back the general timeline back quite a bit, with apps due Jan 10th which is significantly earlier than other years, and the national interview period is relatively condensed to ~2 weeks vs. prior iterations. I e-mailed them to see if they had tentative dates for 2024 and didn't get a response lol. Totally agree on the geographic flexibility part, I'm trying to be as honest with myself as what programs I'd be happy to match at vs. not based on location. While my school has decent international exposure, I've heard that the Canadian match process is a huge black box and very networking dependent (especially in surg specialties) as there are so few spots in a given program, and there aren't really objective measures to compare applicants on (apparently the MCCQE score isn't treated the same as USMLE scores, some/most Canadian med schools don't have clinical grades like the H/HP/P/F system here?)

To be honest, the US system is the amalgamation of the worst parts of medicine for me. Most specialties (including surgical) are plagued by "social medicine" issues. Don't get me wrong, these issues absolutely exist in Canada as well, but seeing attendings and residents playing the role of social worker gets old after awhile. The insurance nightmares, placement issues, billing complexity, and above all, poor non-evidence based medical practice, are amplified on a multiple-fold basis in a system where even the upper-middle class patient has to get creative starting all sorts of GoFundMes and refinancing situations to pay for the OOP costs of their cancer care. Frequent fliers of the low-SES / poorly managed chronic disease variety represent such a substantial cost to the system, and yet there is little incentive to address the fundamental social determinants of health that lead to these situations because hospitals have still found a way to profit off of these pts or exclude them entirely (the business office at my hospital system runs like a well-oiled machine when they need to get that uninsured pt emergency Medicaid coverage and start billing, but have no problem telling that same pt they better not come back for their f/u visit because we don't take Medicaid pts in the outpt setting). I've seen veterans dumped and punted off our service back onto the streets hours after they are admitted because we don't take their insurance and we can't bill them. Ambulances are implicitly routed based on a patients insurance coverage in our city even though legislation (EMTALA) dictates otherwise. Hospitals collude and compete over the fixed number of privately insured patients needing high-reimbursement procedures by disproportionately pouring money into specialties (e.g. ortho, CT Sx, etc.) and deeply underfunding others (primary care, OB/GYN, gen medicine, the less lucrative med subspecialties) to maximize profit and retained earnings. I'm "lucky" in the sense that the specialty I'm going into compensates very well, but my thought process was, if I'm having moral and ethical reservations with the health system here this early on, especially in my specialty, I don't think it's going to feel any better as time passes.

Even at ivory tower "non-profit" academic institutions, the goal at the end of the day is squeezing out as much money from patients, even at the cost of subpar care, unnecessary procedures and workups, etc. It's cool from a med student perspective to see the $1 million workup on the non-specific RUQ pain with ambiguous biopsy and imaging results, but after day 30 of this patient's admission and consults to the entire hospital, you realize that the admission is more about maximizing billing vs. discharging the patient in a reasonable amount of time with an appropriate level of care. Robots are regularly used for procedures and patients that don't need them, often times by surgeons who have no business setting foot near the console. Things like bundled payments, capitation models etc, have slightly helped with this issue, but for the most part, private employer-based insurance and Medicare to an extent are essentially bottomless pits with blank cheque books that absorb the cost of care that is spurred by useless and wasteful healthcare expenditure on an individual patient and systems level basis.

The billions of dollars that are invested in the private system to lead to the "world-class" care are the reason that healthcare is so expensive in the community that serves the vast majority of the country. The pt rooms in our hospital look like 5-star hotel rooms, and it blows my mind that faculty at my hospital will spend their days toiling away churning out low quality, useless pubs on "high value care" when they can't even realize that our hospital system is 100% a part of the problem. Even out in community hospitals or academic satellites, the same culture persists. It's an absolute free for all in terms of fighting over private patients and trying to run up the patient bill to the maximum tolerated amount to keep the doors open. At a systems level, the reason why the job market here is generally better for a lot of surgical specialties is that supply / demand is completely out of touch with the needs of the country. In a mid sized city, you'll see entire 30-specialty department complements duplicated at every academic and large community hospital on every city block while you can go through entire states that don't have a particular subspecialist. There's no incentive to streamline and allocate resources in a for-profit healthcare system. The hub-and-spoke Canadian model that exists in most provinces generates a lot of issues with patient care (esp. wait times), but at least incentives are aligned at trying to keep costs within reason while also providing generally high quality care in-line with the rest of the Western world, with compensation that is roughly similar to the US. Canada really is the only country (+/- Australia) that is able to combine these two things somewhat successfully.

The irony, from a trainee perspective, is that the care and training at some of these big name places that are world renowned is honestly no better (and likely worse) than what you'd get at a community hospital. I worked on a gen surg service here for a month and honestly seeing how questionable the operative skills of the famous department chair, let alone the average attending, was shocking. Many were completely unable to do a standard procedure entirely laparoscopically (when it is the SOC for a given procedure and an uncomplicated pt) and had to convert to open. When I told my friends and family back home in medicine they were surpised. I'm obviously just a MS and in no place to be judging the surgical skill of any attending, but I would genuinely feel uncomfortable having some of these surgeons operate on me or fam / friends seeing what I've seen. These same surgeons will double / triple book ORs and run procedures simultaneously (because $$$), but lack the surgical / technical skill to actually finish these cases in any reasonable amount of time, and so I've had to sit and watch pts who will lie for hours under anesthesia without any surgery going on. Residents can graduate from 5+ year residencies and are potentially unable to operate on their own due to lack of skill development but will have research resumes that rival those of PhDs (although this is probably a trend that isn't unique to the US). Many have to go to fellowship to continue to gain confidence operating independently. We often had residents from "low-ranked" OSH residencies come to our children's hospital to get their peds months in and the skill difference (across multiple specialties) is stark. Home residents take on an observer role whereas these community-trained residents actually get to operate under supervision. If I ever get that twinge in my RLQ, you bet I'm going to get an Uber (a 1-mile ambulance ride can sometimes cost >$1000 OOP here with good insurance), 20 mins over the suburbs to get that lap appy from a surgeon who doesn't have to crack open my sternum to find landmarks lol.

I never really understood how unhealthy the population is here until I saw it for myself clinically. The comorbidities here are out of control and I'd say >90% of surgeons here have BC in bariatrics because I genuinely can count on one hand the number of sub-25 BMI procedures I've been scrubbed into. I've seen pathology that I never thought I'd see in a developed country in my generally nice urban area, and while great from a learner perspective, it's kind of alarming to see the effects of poor (health) literacy and health disparities in the general population.

I think there are a lot of misconceptions in terms of pay differentials and taxation in the two countries as well that are perpetuated in physician communities in both countries. In some specialties, you can definitely make 100-200k on average more south of the border, but in others you can see the reverse trend (e.g. ophtho, cards are sometimes 3-4x the salary that is available here). Likewise income tax rates for physicians are largely not that different between the two (less than double digit difference in effective tax rate, likely within the 1-5% range for most physicians), especially once you take into account things like incorporation. If you account for the vastly different malpractice coverage rates, and the highly litigious med mal landscape here in the US, you really don't end up ahead and may very likely end up behind on a net income basis once accounting for COL. Midlevel encroachment is significant here and puts substantial downward pressure on wages across the board. While general wisdom has been that surgical specialties are safe, having seen the leeway that academic and PP surgeons will give to PAs, I wouldn't be surprised in 15-20 years if PAs are able to do simple procedures independently because every aspect of the system here is incentivized for them to do so. I know that sounds outlandish but just seeing some of the trends in primary and specialty medical care during my few years here it wouldn't surprise me. Physician advocacy is relatively worse here compared to Canada, and I have little faith that specialties / the profession as a whole will be able to band together and push back against the inevitable decline of salaries and scope of practice as midlevels take on more responsibility + pay at the expense of physician comp. I guess I wouldn't have an issue with this if it led to better care and / or was justified, but a NP with an online degree and 500 clinical hours fresh out of school with no work experience shouldn't be allowed to do 1% of their current scope. I'm just a med student, and so I can only imagine, but I've seen a glimpse into the independently-practicing midlevel dumpster fire pts that show up to the ED and it isn't pretty. While raising a family anywhere is expensive in general, I think some people underestimate how much it costs to put a kid through a 4-year college education here +/- the private schooling needed to get there given how lackluster the public school system here is on average.

The crazy large salaries that recruiters are tossing out there exist for a reason; the spots are usually in undesirable locations (either very rural, unpopular flyover states, etc.), or have horrible clinical responsibilities (e.g. q4 in house call). If you want to live in or around a more popular city, you'll have to take a significant pay cut. It's pretty standard to see some surgeons (including specialists and fellowship-trained) in NYC, Boston, LA, Seattle, SF etc. taking salaries in the 200-300k range in academia and only a touch above this for community / PP because these areas are hypercompetitive and oversaturated, and employers know they can get away with depressed wages. Again all of this is highly specialty dependent. but after seeing compensation trends here in the US, it's clear that the golden age of medicine is over.

Also more of a personal preference and highly subjective, but American culture is noticeably more individualistic vs. Canada, and something I hadn't really thought about before I moved here.

 

[Medstart108]

Appreciate the response! As of this app year (2022-2023), the matches are still scheduled to be in the reverse format (Carms second NRMP first, the difference is a week or so). I've noticed that Carms has also pushed back the general timeline back quite a bit, with apps due Jan 10th which is significantly earlier than other years, and the national interview period is relatively condensed to ~2 weeks vs. prior iterations. I e-mailed them to see if they had tentative dates for 2024 and didn't get a response lol. Totally agree on the geographic flexibility part, I'm trying to be as honest with myself as what programs I'd be happy to match at vs. not based on location. While my school has decent international exposure, I've heard that the Canadian match process is a huge black box and very networking dependent (especially in surg specialties) as there are so few spots in a given program, and there aren't really objective measures to compare applicants on (apparently the MCCQE score isn't treated the same as USMLE scores, some/most Canadian med schools don't have clinical grades like the H/HP/P/F system here?)

To be honest, the US system is the amalgamation of the worst parts of medicine for me. Most specialties (including surgical) are plagued by "social medicine" issues. Don't get me wrong, these issues absolutely exist in Canada as well, but seeing attendings and residents playing the role of social worker gets old after awhile. The insurance nightmares, placement issues, billing complexity, and above all, poor non-evidence based medical practice, are amplified on a multiple-fold basis in a system where even the upper-middle class patient has to get creative starting all sorts of GoFundMes and refinancing situations to pay for the OOP costs of their cancer care. Frequent fliers of the low-SES / poorly managed chronic disease variety represent such a substantial cost to the system, and yet there is little incentive to address the fundamental social determinants of health that lead to these situations because hospitals have still found a way to profit off of these pts or exclude them entirely (the business office at my hospital system runs like a well-oiled machine when they need to get that uninsured pt emergency Medicaid coverage and start billing, but have no problem telling that same pt they better not come back for their f/u visit because we don't take Medicaid pts in the outpt setting). I've seen veterans dumped and punted off our service back onto the streets hours after they are admitted because we don't take their insurance and we can't bill them. Ambulances are implicitly routed based on a patients insurance coverage in our city even though legislation (EMTALA) dictates otherwise. Hospitals collude and compete over the fixed number of privately insured patients needing high-reimbursement procedures by disproportionately pouring money into specialties (e.g. ortho, CT Sx, etc.) and deeply underfunding others (primary care, OB/GYN, gen medicine, the less lucrative med subspecialties) to maximize profit and retained earnings. I'm "lucky" in the sense that the specialty I'm going into compensates very well, but my thought process was, if I'm having moral and ethical reservations with the health system here this early on, especially in my specialty, I don't think it's going to feel any better as time passes.

Even at ivory tower "non-profit" academic institutions, the goal at the end of the day is squeezing out as much money from patients, even at the cost of subpar care, unnecessary procedures and workups, etc. It's cool from a med student perspective to see the $1 million workup on the non-specific RUQ pain with ambiguous biopsy and imaging results, but after day 30 of this patient's admission and consults to the entire hospital, you realize that the admission is more about maximizing billing vs. discharging the patient in a reasonable amount of time with an appropriate level of care. Robots are regularly used for procedures and patients that don't need them, often times by surgeons who have no business setting foot near the console. Things like bundled payments, capitation models etc, have slightly helped with this issue, but for the most part, private employer-based insurance and Medicare to an extent are essentially bottomless pits with blank cheque books that absorb the cost of care that is spurred by useless and wasteful healthcare expenditure on an individual patient and systems level basis.

The billions of dollars that are invested in the private system to lead to the "world-class" care are the reason that healthcare is so expensive in the community that serves the vast majority of the country. The pt rooms in our hospital look like 5-star hotel rooms, and it blows my mind that faculty at my hospital will spend their days toiling away churning out low quality, useless pubs on "high value care" when they can't even realize that our hospital system is 100% a part of the problem. Even out in community hospitals or academic satellites, the same culture persists. It's an absolute free for all in terms of fighting over private patients and trying to run up the patient bill to the maximum tolerated amount to keep the doors open. At a systems level, the reason why the job market here is generally better for a lot of surgical specialties is that supply / demand is completely out of touch with the needs of the country. In a mid sized city, you'll see entire 30-specialty department complements duplicated at every academic and large community hospital on every city block while you can go through entire states that don't have a particular subspecialist. There's no incentive to streamline and allocate resources in a for-profit healthcare system. The hub-and-spoke Canadian model that exists in most provinces generates a lot of issues with patient care (esp. wait times), but at least incentives are aligned at trying to keep costs within reason while also providing generally high quality care in-line with the rest of the Western world, with compensation that is roughly similar to the US. Canada really is the only country (+/- Australia) that is able to combine these two things somewhat successfully.

The irony, from a trainee perspective, is that the care and training at some of these big name places that are world renowned is honestly no better (and likely worse) than what you'd get at a community hospital. I worked on a gen surg service here for a month and honestly seeing how poor the operative skills of the famous department chair, let alone the average attending, was shocking. Many were completely unable to do a standard procedure entirely laparoscopically (when it is the SOC for a given procedure and an uncomplicated pt) and had to convert to open. These same surgeons will double / triple book ORs and run procedures simultaneously (because $$$), but lack the surgical / technical skill to actually finish these cases in any reasonable amount of time, and so I've had to babysit pts who will sit for hours under anesthesia without any surgery going on. Residents can graduate from 5+ year residencies and are unable to operate on their own due to lack of skill development (increasingly common at some of the top ranked programs) but will have research resumes that rival those of PhDs. Many have to go to fellowship to continue to gain confidence operating independently. If I ever get that twinge in my RLQ, you bet I'm going to get an Uber (a 1-mile ambulance ride can sometimes cost >$1000 OOP here with good insurance), 20 mins over the suburbs to get that lap appy from a surgeon who doesn't have to crack open my sternum to find landmarks lol.

I never really understood how unhealthy the population is here until I saw it for myself clinically. The comorbidities here are out of control and I'd say >90% of surgeons here have BC in bariatrics because I genuinely can count on one hand the number of sub-25 BMI procedures I've been scrubbed into. I've seen pathology that I never thought I'd see in a developed country in my generally nice urban area, and while great from a learner perspective, it's kind of alarming to see the effects of poor (health) literacy and health disparities in the general population.

I think there are a lot of misconceptions in terms of pay differentials and taxation in the two countries as well that are perpetuated in physician communities in both countries. In some specialties, you can definitely make 100-200k on average more south of the border, but in others you can see the reverse trend (e.g. ophtho, cards are sometimes 3-4x the salary that is available here). Likewise income tax rates for physicians are largely not that different between the two (less than double digit difference in effective tax rate, likely within the 1-5% range for most physicians), especially once you take into account things like incorporation. If you account for the vastly different malpractice coverage rates, and the highly litigious med mal landscape here in the US, you really don't end up ahead and may very likely end up behind on a net income basis once accounting for COL. Midlevel encroachment is significant here and puts substantial downward pressure on wages across the board. While general wisdom has been that surgical specialties are safe, having seen the leeway that academic and PP surgeons will give to PAs, I wouldn't be surprised in 15-20 years if PAs are able to do simple procedures independently because every aspect of the system here is incentivized for them to do so. I know that sounds outlandish but just seeing some of the trends in primary and specialty medical care during my few years here it wouldn't surprise me. Physician advocacy is relatively worse here compared to Canada, and I have little faith that specialties / the profession as a whole will be able to band together and push back against the inevitable decline of salaries and scope of practice as midlevels take on more responsibility + pay at the expense of physician comp. I guess I wouldn't have an issue with this if it led to better care and / or was justified, but a NP with an online degree and 500 clinical hours fresh out of school with no work experience shouldn't be allowed to do 1% of their current scope. I'm just a med student, and so I can only imagine, but I've seen a glimpse into the independently-practicing midlevel dumpster fire pts that show up to the ED and it isn't pretty. While raising a family anywhere is expensive in general, I think some people underestimate how much it costs to put a kid through a 4-year college education here +/- the private schooling needed to get their given how lackluster the public school system here is on average.

The crazy large salaries that recruiters are tossing out there exist for a reason; the spots are usually in undesirable locations (either very rural, unpopular flyover states, etc.), or have horrible clinical responsibilities (e.g. q4 in house call). If you want to live in or around a more popular city, you'll have to take a significant pay cut. It's pretty standard to see some surgeons (including specialists and fellowship-trained) in NYC, Boston, LA, Seattle, SF etc. taking salaries in the 200-300k range in academia and only a touch above this for community / PP because these areas are hypercompetitive and oversaturated, and employers know they can get away with depressed wages. Again all of this is highly specialty dependent. but after seeing compensation trends here in the US, it's clear that the golden age of medicine is over.

Also more of a personal preference and highly subjective, but American culture is noticeably more individualistic vs. Canada, and something I hadn't really thought about before I moved here.

Interesting read for sure, great insight. At the end of the day the American system essentially puts the patient more in the driver seat, its a result of the individualistic focus that is American culture, i.e. "american dream, bootstraps etc.". In Canada, the physician has more power, you essentially hold the keys to the provincial tax coffer and can provide thousands of dollars of services at a stroke of a pen. Its a paternalistic system, the big brother warnings aren't entirely wrong. As a physician, you can turn down a patient for surgery, re-refer them to your colleague and they can wait another 6 months. By this time, the patient probably has already waited 1 year to see you, so they are pretty much on their knees begging you at that point. You do whatever surgery you want because if the patient read online some new fangled minimally invasive thing, you can just tell them you don't do that and offer a 2nd opinion and another 6 month wait.

Canada has its own issues of course, I mean the whole residents not being able to do much thing in the US is hard to say, but I do think the same happens in Canada as well. Surgeons are not allowed to run two rooms here, and usually have to be at least in the building to start the case as long as its not a true emergency. The US talks about "death panels" and while that is a sensationalist, in some ways, case rounds conferences are a bunch of doctors making decisions on whether a patient may live or die. Happens all the time, wouldn't say any physicians come in with nefarious intentions obviously, but if you as the patient want a second opinion after a case conference decision, good luck to you sir.

You are right the residency match is a black box, its more connections based and it will be important to do Canadian electives and at least one Canadian letter if you want to match here. Test scores are not widely looked at, I don't know if many programs understand how USMLE scores are even graded (and certainly wouldn't be able to use them to compare you to applicants without them) and the LMCC scores are widely viewed as not representative. You'll want a letter that attests to your suitability to be a surgeon, your work ethic, teamwork, dependability etc. In the absence of academic indicators like test scores, my suspicion is that is where committees look at things like where you went to medical school for indications (most programs are aware that medical school standards in terms of competitiveness in admissions vary more greatly than they do in Canada). Research will help, networking through research is huge in Canada in surgery. Contacting surgeons and trying to get in on a small project or two will build rapport and can help.

I think if you are a ethics/morals 1st kind of person, you can't tolerate the US system, then yes apply to Canada. Once you are in a residency, more or less you are judged on your residency and there isn't much downside to having graduated from a US medical school in terms of looking for jobs. So really, its just a question of whether or not you are willing to take that risk then of not applying to the US in order to match. Maybe i'm just more of an individualist, but I don't view health systems issues as mine to solve, I view my lens through a more narrow scope, which means as long as I can operate and do a good job, i'm good with it. My view is, if Americans have chosen this system, its because they have chosen to offer different levels of care to people with different incomes, they have made healthcare a product like any other, that's their choice. The Canadian system will absolutely benefit the homeless, poor and downtrodden, who will get reasonable timely care at no personal cost, but it also will mean the 1%ers will have to wait in line for whatever treatment their physician has decided to offer just like everyone else and I guess in the US, those 1%ers run the show and don't like that one bit.

 

[mikeGR]

IMG who trained in US + Canada currently practicing in the US (academic surgical specialty). Agree 110% with @VisionaryTics, esp about job market + certification.

While I also prefer the more "socialized" nature of healthcare in Canada, the problems of their healthcare system are just as frustrating. Undertreatment in the (very) rural communities, long wait lists, and inability to get cutting-edge technology just to name a few. I've worked in 4 different healthcare systems and each country's citizens truly believe theirs is the worst ever. The grass is always greener on the other side.

 

[tmtvt]

Very valid points. I think I'm harsh on the US system because it helps me rationalize the fact that I also want to return back home to Canada for non-medical training reasons as well. In the little free time I have outside the hospital as a resident/fellow and eventual attendinghood, I want to spend it in a place that makes me happy and I'm coming to realize that the US is increasingly not that place for me anymore. It'll be hard to walk away from the life I have here since I've been here for 10+ years and have a great support system, and genuinely enjoyed my time here, but I guess it's time to rip the band-aid off. Definitely should reel in some of the bleeding heart medicine stuff now because it'll end up making me unhappy and unfulfilled in the long run, no matter what country I'm in.

Found a recent journal article (2017) that mentions that says that ~26 Canadian med students applied to the US match and ~46 Canadians in the US applied to Canada. Interested to see how these numbers change if the current match order stands, especially since the applicants/spots ratio in Canada is way tighter than it is in the US (I think its ~1.01 spots / applicant in Can vs. 1.1 in US). When browsing match lists back when I was pre-med at Canadian-friendly med schools, I very rarely saw Canadian matches, and I can't imagine that number going up if Carms keeps it's current timeline. I'm lucky that I get to be a part of the first iteration vs. second, but the "US status" will definitely affect me to some degree. It also seems that some spots are reserved for Saudi Arabian students, but I'm not sure if this is a part of R1/R2 iterations or something separate, and how that affects spots that are actually available in the match? I've also started thinking of backup applying (apparently its far more common in Canada to apply to multiple specialties, especially when going for surgical specialties given how tight the match is?) while I hadn't really entertained the possibility in the US match.

 

[Lem0nz]

Appreciate the response! As of this app year (2022-2023), the matches are still scheduled to be in the reverse format (Carms second NRMP first, the difference is a week or so). I've noticed that Carms has also pushed back the general timeline back quite a bit, with apps due Jan 10th which is significantly earlier than other years, and the national interview period is relatively condensed to ~2 weeks vs. prior iterations. I e-mailed them to see if they had tentative dates for 2024 and didn't get a response lol. Totally agree on the geographic flexibility part, I'm trying to be as honest with myself as what programs I'd be happy to match at vs. not based on location. While my school has decent international exposure, I've heard that the Canadian match process is a huge black box and very networking dependent (especially in surg specialties) as there are so few spots in a given program, and there aren't really objective measures to compare applicants on (apparently the MCCQE score isn't treated the same as USMLE scores, some/most Canadian med schools don't have clinical grades like the H/HP/P/F system here?)

To be honest, the US system is the amalgamation of the worst parts of medicine for me. Most specialties (including surgical) are plagued by "social medicine" issues. Don't get me wrong, these issues absolutely exist in Canada as well, but seeing attendings and residents playing the role of social worker gets old after awhile. The insurance nightmares, placement issues, billing complexity, and above all, poor non-evidence based medical practice, are amplified on a multiple-fold basis in a system where even the upper-middle class patient has to get creative starting all sorts of GoFundMes and refinancing situations to pay for the OOP costs of their cancer care. Frequent fliers of the low-SES / poorly managed chronic disease variety represent such a substantial cost to the system, and yet there is little incentive to address the fundamental social determinants of health that lead to these situations because hospitals have still found a way to profit off of these pts or exclude them entirely (the business office at my hospital system runs like a well-oiled machine when they need to get that uninsured pt emergency Medicaid coverage and start billing, but have no problem telling that same pt they better not come back for their f/u visit because we don't take Medicaid pts in the outpt setting). I've seen veterans dumped and punted off our service back onto the streets hours after they are admitted because we don't take their insurance and we can't bill them. Ambulances are implicitly routed based on a patients insurance coverage in our city even though legislation (EMTALA) dictates otherwise. Hospitals collude and compete over the fixed number of privately insured patients needing high-reimbursement procedures by disproportionately pouring money into specialties (e.g. ortho, CT Sx, etc.) and deeply underfunding others (primary care, OB/GYN, gen medicine, the less lucrative med subspecialties) to maximize profit and retained earnings. I'm "lucky" in the sense that the specialty I'm going into compensates very well, but my thought process was, if I'm having moral and ethical reservations with the health system here this early on, especially in my specialty, I don't think it's going to feel any better as time passes.

Even at ivory tower "non-profit" academic institutions, the goal at the end of the day is squeezing out as much money from patients, even at the cost of subpar care, unnecessary procedures and workups, etc. It's cool from a med student perspective to see the $1 million workup on the non-specific RUQ pain with ambiguous biopsy and imaging results, but after day 30 of this patient's admission and consults to the entire hospital, you realize that the admission is more about maximizing billing vs. discharging the patient in a reasonable amount of time with an appropriate level of care. Robots are regularly used for procedures and patients that don't need them, often times by surgeons who have no business setting foot near the console. Things like bundled payments, capitation models etc, have slightly helped with this issue, but for the most part, private employer-based insurance and Medicare to an extent are essentially bottomless pits with blank cheque books that absorb the cost of care that is spurred by useless and wasteful healthcare expenditure on an individual patient and systems level basis.

The billions of dollars that are invested in the private system to lead to the "world-class" care are the reason that healthcare is so expensive in the community that serves the vast majority of the country. The pt rooms in our hospital look like 5-star hotel rooms, and it blows my mind that faculty at my hospital will spend their days toiling away churning out low quality, useless pubs on "high value care" when they can't even realize that our hospital system is 100% a part of the problem. Even out in community hospitals or academic satellites, the same culture persists. It's an absolute free for all in terms of fighting over private patients and trying to run up the patient bill to the maximum tolerated amount to keep the doors open. At a systems level, the reason why the job market here is generally better for a lot of surgical specialties is that supply / demand is completely out of touch with the needs of the country. In a mid sized city, you'll see entire 30-specialty department complements duplicated at every academic and large community hospital on every city block while you can go through entire states that don't have a particular subspecialist. There's no incentive to streamline and allocate resources in a for-profit healthcare system. The hub-and-spoke Canadian model that exists in most provinces generates a lot of issues with patient care (esp. wait times), but at least incentives are aligned at trying to keep costs within reason while also providing generally high quality care in-line with the rest of the Western world, with compensation that is roughly similar to the US. Canada really is the only country (+/- Australia) that is able to combine these two things somewhat successfully.

The irony, from a trainee perspective, is that the care and training at some of these big name places that are world renowned is honestly no better (and likely worse) than what you'd get at a community hospital. I worked on a gen surg service here for a month and honestly seeing how questionable the operative skills of the famous department chair, let alone the average attending, was shocking. Many were completely unable to do a standard procedure entirely laparoscopically (when it is the SOC for a given procedure and an uncomplicated pt) and had to convert to open. When I told my friends and family back home in medicine they were surpised. I'm obviously just a MS and in no place to be judging the surgical skill of any attending, but I would genuinely feel uncomfortable having some of these surgeons operate on me or fam / friends seeing what I've seen. These same surgeons will double / triple book ORs and run procedures simultaneously (because $$$), but lack the surgical / technical skill to actually finish these cases in any reasonable amount of time, and so I've had to sit and watch pts who will lie for hours under anesthesia without any surgery going on. Residents can graduate from 5+ year residencies and are potentially unable to operate on their own due to lack of skill development but will have research resumes that rival those of PhDs (although this is probably a trend that isn't unique to the US). Many have to go to fellowship to continue to gain confidence operating independently. We often had residents from "low-ranked" OSH residencies come to our children's hospital to get their peds months in and the skill difference (across multiple specialties) is stark. Home residents take on an observer role whereas these community-trained residents actually get to operate under supervision. If I ever get that twinge in my RLQ, you bet I'm going to get an Uber (a 1-mile ambulance ride can sometimes cost >$1000 OOP here with good insurance), 20 mins over the suburbs to get that lap appy from a surgeon who doesn't have to crack open my sternum to find landmarks lol.

I never really understood how unhealthy the population is here until I saw it for myself clinically. The comorbidities here are out of control and I'd say >90% of surgeons here have BC in bariatrics because I genuinely can count on one hand the number of sub-25 BMI procedures I've been scrubbed into. I've seen pathology that I never thought I'd see in a developed country in my generally nice urban area, and while great from a learner perspective, it's kind of alarming to see the effects of poor (health) literacy and health disparities in the general population.

I think there are a lot of misconceptions in terms of pay differentials and taxation in the two countries as well that are perpetuated in physician communities in both countries. In some specialties, you can definitely make 100-200k on average more south of the border, but in others you can see the reverse trend (e.g. ophtho, cards are sometimes 3-4x the salary that is available here). Likewise income tax rates for physicians are largely not that different between the two (less than double digit difference in effective tax rate, likely within the 1-5% range for most physicians), especially once you take into account things like incorporation. If you account for the vastly different malpractice coverage rates, and the highly litigious med mal landscape here in the US, you really don't end up ahead and may very likely end up behind on a net income basis once accounting for COL. Midlevel encroachment is significant here and puts substantial downward pressure on wages across the board. While general wisdom has been that surgical specialties are safe, having seen the leeway that academic and PP surgeons will give to PAs, I wouldn't be surprised in 15-20 years if PAs are able to do simple procedures independently because every aspect of the system here is incentivized for them to do so. I know that sounds outlandish but just seeing some of the trends in primary and specialty medical care during my few years here it wouldn't surprise me. Physician advocacy is relatively worse here compared to Canada, and I have little faith that specialties / the profession as a whole will be able to band together and push back against the inevitable decline of salaries and scope of practice as midlevels take on more responsibility + pay at the expense of physician comp. I guess I wouldn't have an issue with this if it led to better care and / or was justified, but a NP with an online degree and 500 clinical hours fresh out of school with no work experience shouldn't be allowed to do 1% of their current scope. I'm just a med student, and so I can only imagine, but I've seen a glimpse into the independently-practicing midlevel dumpster fire pts that show up to the ED and it isn't pretty. While raising a family anywhere is expensive in general, I think some people underestimate how much it costs to put a kid through a 4-year college education here +/- the private schooling needed to get there given how lackluster the public school system here is on average.

The crazy large salaries that recruiters are tossing out there exist for a reason; the spots are usually in undesirable locations (either very rural, unpopular flyover states, etc.), or have horrible clinical responsibilities (e.g. q4 in house call). If you want to live in or around a more popular city, you'll have to take a significant pay cut. It's pretty standard to see some surgeons (including specialists and fellowship-trained) in NYC, Boston, LA, Seattle, SF etc. taking salaries in the 200-300k range in academia and only a touch above this for community / PP because these areas are hypercompetitive and oversaturated, and employers know they can get away with depressed wages. Again all of this is highly specialty dependent. but after seeing compensation trends here in the US, it's clear that the golden age of medicine is over.

Also more of a personal preference and highly subjective, but American culture is noticeably more individualistic vs. Canada, and something I hadn't really thought about before I moved here.

This is a huge wall of text with a lot of opinions that I think are reflective of a very narrow experience. I am a super sub specialist in a city of 500k serving ~1.5 million people and I just don't have these problems. Insurance never comes up. We take and treat everyone that comes through the door the same. Sure, occasionally I can't get a PET CT when I wanted one or an MRI but there are ways around that. There are no road blocks to me performing surgery on patients, ever, if that is how I feel they need to be treated.

I hated being in the ivory tower settings the times I had to be. There was some value, but it did not warrant the cost or the superiority complex.

Rather than struggle in the Canadian system for what sounds like perhaps a decade of your life trying to get a job, and having freely admitted you think community training may be better (hint, it is), I think you should expand your horizons and go to a very busy community residency and just find a city you like that allows you to treat patients the way you want to. Find a medium sized town like mine. If you're the only hospital system, or one of two hospital systems, you don't have to turn anything away because you're it. There's no county hospital to dump things into. All those fly over states and 'undesirable' positions you just described that pay you in gold bricks? They're really cool places to live and work, the towns are small enough that lots of people get to know you, and you actually feel like part of a community. I felt like I knew no one in Manhattan and Philadelphia when I lived there. Have not had that problem in the Midwest or the smaller places I've visited/trained in and it was the opposite - people were extremely welcoming and wanted me to feel like I belonged and mattered.

Two cents from the Midwest, having been everywhere from rural training settings to MSKCC at Manhattan and all of the things in between. I think I've trained at maybe ~30 different hospitals at this point and I'm currently at a massive community non-profit system in a medium sized town and its absolutely perfect.

 

[tmtvt]

This is a huge wall of text with a lot of opinions that I think are reflective of a very narrow experience. I am a super sub specialist in a city of 500k serving ~1.5 million people and I just don't have these problems. Insurance never comes up. We take and treat everyone that comes through the door the same. Sure, occasionally I can't get a PET CT when I wanted one or an MRI but there are ways around that. There are no road blocks to me performing surgery on patients, ever, if that is how I feel they need to be treated.

I hated being in the ivory tower settings the times I had to be. There was some value, but it did not warrant the cost or the superiority complex.

Rather than struggle in the Canadian system for what sounds like perhaps a decade of your life trying to get a job, and having freely admitted you think community training may be better (hint, it is), I think you should expand your horizons and go to a very busy community residency and just find a city you like that allows you to treat patients the way you want to. Find a medium sized town like mine. If you're the only hospital system, or one of two hospital systems, you don't have to turn anything away because you're it. There's no county hospital to dump things into. All those fly over states and 'undesirable' positions you just described that pay you in gold bricks? They're really cool places to live and work, the towns are small enough that lots of people get to know you, and you actually feel like part of a community. I felt like I knew no one in Manhattan and Philadelphia when I lived there. Have not had that problem in the Midwest or the smaller places I've visited/trained in and it was the opposite - people were extremely welcoming and wanted me to feel like I belonged and mattered.

Two cents from the Midwest, having been everywhere from rural training settings to MSKCC at Manhattan and all of the things in between. I think I've trained at maybe ~30 different hospitals at this point and I'm currently at a massive community non-profit system in a medium sized town and its absolutely perfect.

For sure, as a med student, I'd argue its almost impossible to not have a very narrow view on things since we've only directly experienced one hospital system in a certain pt pop in a clinical sense and I'm limited by minimal experience in the profession. The poster asked for my opinion on why I don't want to stay here and so I gave a long rambling response to it lol. I'm looking to focus on programs that have good community / county exposure, and I'm currently planning aways at places that I think check these boxes. The specialty I'm applying for is disproportionately concentrated at academic centers, and so a community-based training program is largely out of the question. I know that I don't want to practice or live here long-term (for medicine and "non-medicine" reasons), I guess I'm just not sure if the right exit option is residency, fellowship, or as an early attending. If I do end up staying, I'd most likely have to leave the country regardless as >90% of non-US citizens receive a J-1 visa which requires you leave the country at the end of training for at least 2 years. Maybe the best path forward for me is picking a specialty that I'm not as passionate about as it doesn't have the same job limitations back home.

I agree there are way better practice environments that the one that I'm in, I'm just jaded by my experience in mine. Lived in 7 states during my time here in all the major time zones (from very rural town of <10k in a rural state, to 5MM+ city), and there are cool places to live in non-coastal areas. I guess my own personal reservations with these areas don't stem from livability issues, but rather the general healthcare environment in a lot of them. Most of these areas tend to be in states that rank near the bottom in terms of health care quality / funding at the state level. On average, they tend to have unhealthier pt populations with more comorbidities, but on the other hand, they have a more lenient medical malpractice environment. I guess I'd argue that the reason that many of the jobs in these areas that have the 75+ percentile salaries is a function of supply/demand mismatch and just reflects market dynamics; they're definitely the right fit for some people, it's just that most people don't want them (for location, job responsibilities, other reasons, etc.), which is why they have salaries that reflect that. I'm probably the stereotypical Millennial in the sense that I just prefer the coasts to the interior, as someone that's not from there, but a lot of people my age end up in places they don't expect due to other obligations and life events.

I have a family member who practices in the rural part of a Midwestern state at a large non-profit community system and has an experience that lies somewhere between what you described and my experience. At their hospital, there are separate scheduling priorities and appt offerings based on insurance status (similar to my experience). For example, I feel like I'd be hard pressed to find an orthopod who's scrambling to schedule the 60 yo in need of a THA with a low-quality high-deductible plan or pt on a public plan over the platinum-tier PPO Aetna pt who really wants the robot-assisted procedure if they all had similar clinical severity of disease and indication for the procedure, but maybe that's just my cynicism. Based on one of the previous responses, with limited OR time in Canada, surgeons have a large amount of power in allocating and timing care (likely way more than they should). I guess I prefer this environment when the insurance variable is taken out of the picture in terms of implicitly/explicitly biasing my personal practice, even though there are significant ethical and moral issues in this model as well.

The moment the payer mix at a hospital deviates from ~50/50% private/public split (the number that most hospital CEOs at the major academic and non-profit centers cite as the tolerable threshold for public plans) in favour of the latter, the system becomes unprofitable, and something has to give (quality / allocation of care by payer type, otherwise the local/state/fed government has to intervene with subsidies that don't fill the gap ). If an area's payer mix deviates from this threshold in the wrong direction, it's hard to envision how care isn't impacted. With the economy due for another recession and current employment levels, I just don't see the landscape looking better as millions are poised to lose their employer-sponsored insurance, and this seems to happen on a q15 year cycle with the business cycle. At an individual level, I feel like I'd sub-consciously or consciously have to cherry pick pts, based on an areas demographics (target a hospital in a high income area) or meet the demands of PP partners or a hospital CFO/CMO in terms of maintaining the right pt mix and procedures to keep the operation running. Maybe / hopefully I'll find a non-profit community institution like yours, or an HMO, where insurance isn't as critical of a variable, or go the county route, if I end up staying here.

 

[bluelinguini]

@tmtvt I'm currently applying to medical schools in the U.S. and Canada as a Canadian citizen who has lived in the U.S. for ~10y now. I was wondering if I could PM you and ask you some questions if you don't mind! I'm finding it is rather scarce to find someone with a similar experience so I'd really appreciate the help!

 

[leafy0011865]

@tmtvt Can I talk to you about cross-border matching? I'm a med student trying to figure out this cross-border matching situation and will be graduating shortly after you.