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I wanted to comment on MacLellan and colleagues’ research article,1 which was also featured on the cover of the September issue, regarding examination outcomes of international medical graduates (IMGs). I am a family physician devoted to teaching in an academic centre, and I worked at McGill University in Montreal, Que, last year; I am also a recent graduate of University College Dublin in Ireland. As such, I believe that I have some insight into the data presented, which was not mentioned in the article.
The authors comment that “in spite of the pre-residency assessment tools” IMGs in Quebec have substantially lower pass rates on their Certification in Family Medicine examinations. They speculate on many possible causes, but omit a big flaw in the Quebec selection process: Recent graduates of international medical schools are actively discouraged from even applying to Quebec because of the “pre-residency requirements” imposed on them. Personally speaking, despite family ties to Montreal and an undergraduate degree from McGill University, I did not apply to a single Quebec University in the Canadian Resident Matching Service because it would have meant not working for at least an entire year before beginning residency. Very few of my colleagues, many of whom are now working at highly rated institutions in Canada and the United States, could have afforded to take a year off to only potentially get a spot in Quebec, given the extra requirements. Further, these extra pre-residency courses, French tests, and examinations impose further financial burden on already highly indebted students. My suspicion, based on anecdotal experience from working in Quebec, is that the IMGs captured in this study are further away from their medical training and thus less familiar with many of the modern patient-centred and evidence-based approaches crucial to the Certification examination. I would be curious to see national data comparing the results of graduates from other programs in which the applicant pool was of a higher standard. Residency matching is undoubtedly a competitive process and there are many highly capable applicants; to suggest that adding an extra year of assessments will make better physicians is counterproductive. The reality is that inviting the best candidates—trained locally and abroad—to compete for spots will lead to the highest-quality graduates. Imposing extra requirements, which force recent graduates to delay further training, only pushes the top applicants to schools in the United States or Europe rather than having them return to Canada. I hope that the authors will consider comparing national data to their further research to determine whether these trends are consistent in programs able to recruit direct-entry medical graduates without the undue imposition of extra requirements.