Shut out at home, Canadians flocking to Ireland's medical schools - and to an uncertain future
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* Patrick Sullivan

Canada has a 17th medical school. It's located several thousand kilometres east of Newfoundland, and it has become a haven for Canadians who find it difficult or impossible to enter 1 of Canada's 16 schools. FIGURE 1

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/162/6/868/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/162/6/868/F1)

Figure 1. Twelve of the more than 100 Canadians now studying medicine in Ireland

The Atlantic Bridge Program, which recruits North American medical students for the Irish schools, says more than 100 Canadians are currently enrolled in medicine at University College Dublin, University College Cork, Trinity College Dublin and the Royal College of Surgeons in Ireland. They outnumber the first-year students at 9 of Canada's 16 medical schools, and their total is roughly double the size of the first-year class at the University of Saskatchewan.

These young expatriates - most are in their mid- to late 20s - appear undeterred by annual tuition fees of $30 000, high living costs, the prospect of huge debt loads and uncertainty about their professional future. None of the students interviewed by *CMAJ* expressed any doubts about the route they have chosen, but all have doubts about whether they will ever be allowed to practise in Canada. Still, the outcry over the country's physician shortage has left many of these "Irish Canadians" feeling optimistic.

"I expect at some point to have the option of practising in Canada, whether I do my residency there or elsewhere," says Jason Blair, 28, of Manotick, Ont., a second-year student at the Royal College of Surgeons in Ireland. "I say this because I believe there will be a short-age of doctors, even if the government acts now to increase enrolment.

"In the coming years, I think the government will have to attract doctors from outside the country. In a sense, I bet on this by deciding to go to school abroad. This could turn out to be overly optimistic, but I am an optimist."

And there may be reason for at least some optimism. "It is difficult to predict where we are going as far as opportunities for IMGs [international medical graduates] in Canada are concerned," says Sandy Banner, executive director of the Canadian Resident Matching Service. "I believe there will be an expansion of our postgraduate training complement in the near future, and as there are no additional Canadian grads yet, these positions will be filled by more and more IMGs. But remember, that's just a prediction - none of this has come to pass."

However, support for such a move is growing. Last fall the Canadian Medical Forum, which includes the CMA, issued a call for an increase in the number of government-funded training positions from the current level of 100 slots per 100 medical school graduates to 120/100.

Banner notes that there was no expansion for the residency match that took place earlier this month. However, she says a few more IMGs are being matched each year, "and the 'Irish Canadians' are more likely to be successful than some others."

She also notes that completion of a Canadian residency is not the only route to a practice in Canada. "If they have completed some postgraduate training somewhere, they should remember that more than 700 limited licences [they restrict the location of practice and/or type of practice] were granted to IMGs in Canada in the last short while."

All of this is good news for Ontario natives Michael Bengough, 25, and Kim Wynd, 26, who are in the third year of a 6-year program at University College Dublin (UCD). Odds are good that this married couple would eventually have been accepted by a Canadian school - their respective MCAT scores were 34 and 30, both had first-class honours while undergraduates and both hold master's degrees. Bengough had received an interview at Queen's and Wynd was on the waiting list at Western.

So why Ireland? "Chances were not good that we would both be accepted into the same [Canadian] school in the same year," says Bengough. "Moreover, every year that we spent reapplying to Canadian schools pushed the commencement of our real lives - home, family, et cetera - back by a year."

Maureen Keenan, 28, another third-year student at UCD, offers similar reasons. She had been interviewed by UBC and was encouraged to reapply because she was considered "a very strong candidate." When she was accepted by UCD, she decided to take that offer rather than risk rejection again.

Is there a stigma attached to having to attend school outside Canada? "I do not feel inferior at all," says Calgary native Dr. James Stone, 29, who graduated from UCD in 1999 and is completing an internship year at St. Vincent's Hospital in Dublin. "The medical schools here are of tremendously high quality."

Jason Blair agrees. "Someone said that for every spot in medical school in Canada, there are 4 qualified candidates. I simply see myself as 1 of the 3 who lost the draw. As far as the training I receive here, I feel that it is as good as or better than what I would receive in Canada. This school has been training some of the world's best doctors for 250 years."

Asked whether she felt there was a stigma attached to her education, 25-year-old Sara Junaid, a second-year student at UCD, replied: "On the contrary. I feel like I'm getting the best of both worlds: studying medicine and learning about another country and culture. I think we'll bring something back to Canada from the Irish approach to medicine and life."

But will Canada want them back? Dr. David Hamilton hopes so.

## Stuck in limbo between Syracuse and Thunder Bay

Even though his career is currently on hold as he awaits word of a residency in Canada, the wait is giving him a chance to spend time with his wife and 2 young children and to reflect on the differences between medicine in Canada and the US.

Hamilton, who graduated from the Royal College of Surgeons in Ireland 3 years ago, had completed 2 years of a psychiatry residency at the State University of New York in Syracuse when, for family reasons, he decided to seek to finish his residency in Canada. His wife, Dr. Catherine Mann, is completing a psychiatry residency at the University of Ottawa.

He arrived back in Canada after hearing "through the grapevine" that the Ontario Ministry of Health was awarding some residency positions on a case-by-case basis if a community showed a demonstrated need. Hamilton then got in touch with officials in Thunder Bay, Ont., who agreed to fund the last 2 or 3 years of his residency in Canada in return for a commitment to practise in that Northern Ontario city. However, his transfer to a residency program at the University of Ottawa has yet to be approved by the province.

"Do I have any regrets? In the grand scheme of things, no, because it's great to be here with my family. If this [residency application] does fall apart, then I'm going to apply as an IMG."

Ontario currently provides 24 residency slots for graduates of foreign medical schools, but there are rumours that the number will rise shortly. Hamilton says he always has the option of moving to the US, but he has no desire to do that. "I simply think that our system is superior," he says. "In Syracuse I didn't like managed care at all - it forces physicians to play games with the insurance companies." And even though Syracuse is just a 2-hour drive from the Canadian border, "the cultural differences are huge - it's a different world there."

Hamilton, who went to Ireland after failing to gain acceptance at an Ontario school, says he was fortunate to leave Ireland without major debts, thanks to financial help from his father.

As for the future, he hopes to be working again within a year - and with any luck he'll still be in Canada. Asked if he had a message for Canada's doctors, he said: "There are a lot of Canadians [trained in Ireland] who want to practise in Canada, anywhere in the country."

Indeed, Canada remains a magnet for most of these students. Stone says he would return to Canada if he could, but residency training raises huge questions, particularly because he wants to be a surgeon. He has applied for a surgical residency in Ireland. "The most important thing to me is to be a surgeon, and if that means I cannot train or practise in my own country, then I will have to go elsewhere."

Asked if he had a message for Canadian doctors, he said: "Canada spends plenty of money educating doctors who will not practise in Canada. To date I have cost the system nothing. And I am a Canadian. I always have been and I always will be."

## "In hock up to my eyeballs"

The major concern for most of the expatriates is rising debt loads. Foreign students there pay about 3 times more in tuition fees - about $30 000 annually - than the most expensive Canadian medical school, and the fees are accompanied by Europe's high cost of living.

"I expect to be in hock up to my eyeballs for a while after graduating," says 24-year-old Aamir Jeewa, a third-year student at UCD. Although she does get some Canada Student Loans, this is "only a drop in the ocean." It costs most Canadian students between $45 000 and $50 000 a year to attend school in Ireland. Jason Blair, for instance, expects to owe around $300 000 by the time he graduates. He is financing his studies through savings - he worked for a year after completing an MBA at Western - and bank loans, "but the majority is a loan from my parents." FIGURE 2

![Figure2](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/162/6/868/F2.medium.gif)

[Figure2](http://www.cmaj.ca/content/162/6/868/F2)

Figure 2. Michael Bengough and Kim Wynd: Ireland provided a chance to study medicine together

Meanwhile, Don Wakelin, a 26-year-old University of Victoria graduate who enrolled at University College Cork in 1996, is philosophical about the debt of $146 000 he expects to amass. "The financial assault incurred with an overseas education is substantial, but this is still cheaper than studying medicine in the US."

Bengough and Wynd expect to owe $250 000 when they graduate, but Wynd explains that this only represents half of the actual cost. "The rest is being provided by our families, for which we are eternally grateful."

Jason Blair, who scored a 31 on the MCAT, had a 3.5 grade point average at McGill and finished in the first quartile of students in Western's MBA program, was asked if he had a message to pass on to Canada's physicians and politicians.

"There is a group of dedicated and motivated Canadians studying medicine abroad. Most, if not all, would like to come back to Canada. Please make it easier for us to decide to return."

## "If Canada doesn't want us, somebody else will"

How did Victoria resident Ilana Porzecanski end up in the fourth year of a 6-year medical program at University College Dublin? "Two reasons," she says. "Mainly, they accepted me, and I didn't know when or if UBC would. And I was desperate to study medicine. I didn't want to settle for anything less than my dream of being a physician."

Porzecanski, 28, was probably on the borderline for acceptance at a Canadian school - she ended her undergraduate years with a B+ average and had a combined total of 26 in the 3 major components of the MCAT. Since moving to Ireland in 1997, she has been in the top 20% of her class. FIGURE 3

![Figure3](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/162/6/868/F3.medium.gif)

[Figure3](http://www.cmaj.ca/content/162/6/868/F3)

Figure 3. Ilana Porzecanski: "Don't forget about us."

Porzecanski expects to owe $175 000 by the time she graduates. She receives about $6000 a year in federal student loans, which helps cover living expenses, but she is ineligible for provincial funding because she is a medical student studying overseas.

Her tuition costs $28 000 a year, while living expenses amount to $1400 a month; her interest payments currently total $350 a month. She is not sure if she will ever practise in Canada, where both her parents are physicians, and is bitter that foreign nationals who train in Canada have a better chance of getting a residency position than Canadian citizens who train abroad.

"Right now, the situation is this. We cannot get residency training in Canada, except perhaps in our province of origin." Porzecanski says she would have to spend 1 year establishing residency, then 36 weeks doing clinical rotations, then write an exam and do a clinical skills exam. "Then, only the top 4 candidates get to do a 6-month pre-residency rotation. Then, only the top 2 candidates are offered a 2-year family practice residency." (She outlines her own proposal in a letter to the editor in this issue. -Ed.)

So odds appear slim that Porzecanski will ever hang her shingle in Canada, even though that's what she'd love to do. "As an Irish graduate, I would be welcome in New Zealand, Australia and Europe," she says. "If I end up specializing, I will go to the US. I am thinking strongly of moving there permanently."

Has the tough and expensive road to medical training been worth it? Porzecanski isn't sure. "I thought my problems would be over once I got into medicine, and life would be perfect. But now I feel that the problems are just starting."

She has wondered if she should have entered another profession such as law, which would have allowed her to stay in Canada and receive Canadian financial support. But she says her attitude always changes after she spends a day "in the clinics. I'm so happy and energized then that I'm sure I made the right choice.

"Would I do it again, knowing what I know now? Yes. All of the Canadians here are optimistic that things will work out in the end, because if Canada doesn't want us, somebody else will."

Does she have any message for Canada's doctors? "Don't forget about us," she says. "Give us a chance to come back to Canada to train."

## Paras Naik, MD: How Scotland produced Canada's youngest physician

FIGURE 4 If Paras Naik was a typical Canadian student, odds are he would be entering medical school in Canada in September instead of graduating in June from the University of Glasgow. At age 22, he'll become the youngest Canadian to hold a medical degree.

![Figure4](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/162/6/868/F4.medium.gif)

[Figure4](http://www.cmaj.ca/content/162/6/868/F4)

Figure 4. Paras Naik: Canada's youngest doctor may never practise here

Naik had all the right credentials for pursuing a medical education here: a 94% average in his final year of high school in Markham, Ont., and acceptance into undergraduate studies at the University of Toronto, McMaster and Queen's.

So why did he leave? "With the visible cutbacks in enrolment in the early 1990s, the idea of studying medicine outside Canada became a clearer option," says Naik. "With the possibility of completing a bachelor's degree without any guarantee of entry into a Canadian medical school, it seemed that my desire to get a medical degree would be easier to realize outside my own country."

He responded by contacting 10 medical schools in the UK and Ireland in 1995, and chose Glasgow's 5-year program over the 6-year program in Ireland. By the time he receives his MB ChB degree in 3 months, he expects to owe £82 000 (Can$184 500). "As a child of a single-parent household, I have found it very challenging to finance my education here," he says, "and a deteriorating exchange rate hasn't helped. Financial matters have been a constant stress for my mother and me for the past 4 and a half years. I am just glad that the financial burden will be put to rest in a few months."

So what does the future hold for Paras Naik, MD? As graduation approaches, he's not sure. Although he would like to practise in Ontario, the deck is clearly stacked against this. Naik notes that he, like all foreign medical graduates, can apply for only the second iteration of the residency match - his Canadian citizenship provides no advantages. "I feel that securing a residency post will indeed be challenging and will lead to a great deal of frustration and time delay."

With that in mind, he intends to spend another year in the UK in order to gain certification from the General Medical Council and make some money. "I will [then] make my best endeavour to get a residency in Canada."

He's not holding his breath. In November 1999 he wrote to 4 Canadian residency directors whose programs were unfilled in the 1999 match. "I expressed my interest in their programs and requested further information and advice. To date I have not received any acknowledgement." If his attempts to return for Canadian training fail "it looks very likely that I will enter residency training in the US and practise there."

Naik finds this ironic, given Canada's current physician shortage. "I would like to emphasize what I felt when I left Mount Sinai Hospital on Aug. 27, 1999, after the last day of my Canadian elective in internal medicine. After being well looked after during my stay, I could not believe that I would never be able to return to this institution. I wasn't told that this was the case, but I just knew that it was a distant and rare possibility. As I slowly paced to my car. I gave one glance over my shoulder at the hospital and asked myself: 'When will this ever make sense?' To this day I still haven't been able to answer that question."

## Irish schools actively recruiting Canadians

Peter Nealon is building a bridge between Canada and Ireland, one medical student at a time. Nealon is director of the Atlantic Bridge Program, which was created by Ireland's medical schools to attract medical students from North America in the face of growing competition from offshore medical schools in the Caribbean and elsewhere. The 10-year-old program acts as a clearing-house for North American students interested in studying medicine in Ireland.

The number of calls it's getting from Canadians is increasing in lockstep with the decline in the number of first-year positions at Canada's 16 medical schools. "In the last 2 to 3 years we have noticed an increase," says Nealon, who now receives about 70 applications a year from Canadians. "Basically, we say that the schools in Ireland are your best bet if you don't get in to a Canadian medical school."

He's impressed by the quality of the Canadian students, almost all of whom have been rejected - some more than once - by schools in Canada. About half of these applicants are eventually accepted by an Irish school. Nealon says the Canadian standards "are very high" and the students who go to Ireland almost invariably do well.

"We're fairly straightforward," he says. "We get about 300 applications a year from North America. We could probably get 1000 if we wanted to, but we counsel the ones we think couldn't cut it and advise them that they might be wise to pursue something else."

So what happens when the Canadians graduate? "Their best bet is to get into the States," he says. For non-US citizens, this means they must be fully licensed, so the Canadians should plan on doing an internship year in Ireland. Once that is done, explains Nealon, it is relatively easy to land a residency position in the US because the country has about 22 000 residency slots but produces only 15 000 new doctors a year. "The Irish students get snapped up for the good residencies," he says.

"There's an interesting angle to this," he added. "Some of the applicants from Canada tell us that they 'just want to be doctors' and they'll worry about issues like residencies in 5 or 6 years. But some of them have everything planned out in advance, and they tell us that they wanted to go to the States anyway."