Journey into the unknown: considering the international medical graduate perspective on the road to Canadian residency during the COVID-19 pandemic.

The COVID-19 pandemic has had a tremendous effect on education programs worldwide, including medical education. Particularly, International Medical Graduates (IMGs) planning to pursue residency training in Canada have been profoundly impacted. Cancellation of away electives, as well as changes to the format, timeline, and requirements of mandatory medical licensing exams has left IMG residency applicants in uncharted territory. Given that IMGs comprise up to 25% of the Canadian healthcare force, and often are based in underserviced areas, the licensure and eligibility of IMGs to continue to enter the Canadian healthcare force is of the utmost importance in the midst of the COVID-19 pandemic. As the pandemic evolves, it is imperative that key decision makers and stakeholders continue to consider the downstream effect for IMGs and their eligibility to practice in Canada.

COVID-19 has had a tremendous impact on education programs worldwide, including the future of International Medical Graduates’ (IMGs) postgraduate application process. In Canada, IMGs must fulfill additional criteria to apply for residency programs. They are required to complete mandatory written and clinical licensing exams prior to applying for residency, and ideally would undertake North American electives to garner Letters of Recommendation (LoRs) to strengthen their applications. The COVID-19 pandemic has led to cancellations of IMGs’ electives and affected medical licensing exams with significant implications for most IMGs. Highly trained and diverse, IMGs make up a quarter of practicing physicians in Canada and are a crucial part of the healthcare system.[1],[2] With increasing physician demand, along with the current uncertainty amidst the COVID-19 pandemic, IMGs could fulfill an important role. It is imperative, both from a perspective of fairness and health system need, that key decision makers and stakeholders consider the profound impact of the current pandemic on the future of IMGs’ eligibility to practice in Canada.

For the 2020 match, over 1200 IMGs applied for 325 available IMG residency positions through the Canadian Residency Matching Services (CaRMS).[3] These applicants are immigrant physicians and Canadians studying abroad who have acquired medical degrees outside of Canada or the U.S.[1] The Medical Council of Canada requires that IMGs complete written and clinical licensing exams: the MCCQE1 and National Assessment Collaboration (NAC) exam, before the CaRMS application process.[4] Usually, these exams have played a large role in consideration for residency interviews, with scores used to compare IMG applicants. This differs from Canadian Medical School Graduates (CMGs) who have the flexibility of writing the MCCQE1 after matching to residency. Due to physical distancing regulations, written exams were initially cancelled for many applicants with limited availability for rescheduling. Notably, the NAC, a clinical skills assessment required for IMG applicants, that must be completed in Canada, now has a modified pass/fail scoring system. Travel restrictions and quarantine requirements are additional barriers for IMGs outside Canada. Now more than ever it is essential that licensing bodies and educators advocate for the best interests of IMGs who must overcome multiple barriers to completing mandatory exams in time for residency applications.

Another significant concern is IMGs’ inability to complete elective rotations in Canada. Electives are crucial learning opportunities for IMGs to showcase that their clinical skills translate to appropriate and safe clinical practice in the Canadian healthcare system.[5] Electives also help in acquiring strong, specialty specific LoRs for their CaRMS applications. Unfortunately, all IMG Canadian electives have been cancelled due to COVID-19, which for many IMGs, may have been their only chance to experience Canadian clerkship electives. Unlike CMGs who are represented by the Canadian Federation of Medical Students, IMGs applying to CaRMS do not have an official organization advocating for them, and these changes have major consequences on their residency application process.

Without electives and recently modified exams, assessment of candidates will likely have to change, and IMGs have valuable and unique experiences that may help them stand out. In the upcoming application cycle, IMGs’ selection criteria may require amendment, such that extracurricular activities, research involvement and personal letters of intent may be of extra value. Past experiences in teaching, volunteering, and leadership roles, may carry more weight. This match season may benefit IMGs from varied educational or career backgrounds, who are using their skills to help their communities fight COVID-19 or showcasing self-guided learning to expand their education. If residency programs amend selection criteria, timely communication to IMGs would help alleviate their uncertainties.

One exceptional challenge for IMGs is voicing concerns around changes to residency matching during the pandemic without a unified organizational body. Given the different requirements and deadlines for IMGs, in addition to unique changes at the program level, IMGs have the added stress to remain vigilant and abreast of recent changes to ensure their eligibility for programs is unaffected. As students world-wide express their concerns regarding the unique impact of COVID-19 on their training or future employment, one thing remains clear; IMGs’ success relies heavily on having a national administrative body that advocates for our interests.

Ultimately, COVID-19 has highlighted the worldwide need for doctors, with some countries accelerating graduation to cope with the increased need. IMGs make up approximately 25% of the physician workforce in Canada and play a key role in underserved communities.[1],[2] Their success depends on many working parts and it is crucial that their viewpoints are taken into consideration in the decision-making process to ensure their success in the upcoming residency application process.