Canada Residency Guide

PART I: Basic Requirements

The following represents the basic requirements in order to apply for a residency position in Canada. Some students opt to take time off after graduation to study for and take the required exams. However, it is recommended that you complete them during medical school. This is because grades reflect your performance under time constraint. If you take months and months to study for an exam, it is expected that you’ll do much better and a higher score may look less impressive to some. Furthermore, there tends to be a preference for graduates applying directly during or immediately after the completion of medical school. The aforementioned are evidenced by the significantly higher average exam scores seen in older applicants who successfully match.

This is a 2.5-hour exam where you will be seeing 12 standardized patients (essentially, highly skilled actors) while being observed by a physician examiner. It is similar to the Step 2 CS in content and scope, except that you receive a numbered score evaluating your performance. This score is used to directly compare you to other applicants, similarly to the multiple-choice exams (i.e. USMLE Steps 1 and 2, and MCCQE Part 1). When considering this examination, you should think about the following:

Where am I going to take it? Unfortunately, there are only a handful of locations where this test is administered, and they are all within Canada. They are also only administered twice a year (usually March and September). Go to the MCC website to find which locations and dates offer the test. You will need a Physicians Apply account in order to apply for this and other Canadian exams. Note that applications for these exam occur during a short window of time, so you need to be ready to apply for them when that time comes. Moreover, upon applying, you can select up to 3 location preferences. There are no guarantees that you will receive your preferred location, so do not make travel plans until a location has been assigned to you.

When should I take it? Our recommendation is to take it close after your MCCQE Part 1 or USMLE Step 2 CK exam so that medical knowledge regarding differential diagnosis and investigation is fresh in your mind.

How should I study for it? The general consensus is that the most important thing is to get plenty of practice with one or more study partners, either in person or over online voice and video applications. Ideally, you should study in groups of 3, where you each take turns being the examiner, patient, and examinee. The information needed to do well on the exam should be contained in NAC OSCE: A Comprehensive Review and OSCE and Clinical Skills Handbook. Some people also suggest First Aid for the USMLE Step 2 CS for additional cases and in order to practice creating a solid differential diagnosis from a vague presentation. You can also find Facebook groups for international students looking to take the exam where you can find study partners. Additionally, you may sparsely find some information of this exam on the following notable forums/discussion spaces:

How long do I need to study for it? This exam is exclusively taken by foreign students and doctors. Fresh graduates generally study intensively for about 1 month, while those who have been out of practice for a while usually take longer, up to 3 months or more. Some also opt to take preparatory courses.

This is an 8.5-hour exam broken up into a 4-hour morning MCQ session, a 3.5-hour afternoon CDM (Clinical decision-making) session, and an approximately 1-hour lunch break. CDM is delivered on the computer through 38 patient cases where you can respond to questions via short answers or selecting multiple answers out of a list of possible options. When considering this examination, some of following items may come up:

What happened to the MCCEE? Previously, foreign students and graduates needed to pass a 3.5-hour MCQ exam called the MCCEE (Evaluating Exam) before they could sit the MCCQE Part 1. As of 2019, this exam is being phased out and you may challenge the MCCQE Part 1 directly.

Where am I going to take it? Until now, this exam was only administered twice a year, and in Canada alone. As of 2019, you will have multiple opportunities to take it, and it will be delivered worldwide through Prometric Test Centers. Go to the MCC website to find which locations and dates offer the test. You will need a Physicians Apply account in order to apply for this and other Canadian exams. Once you receive approval to take this exam, you will have 12 months to take it.

When should I take it? This exam is ideally taken after you have completed Year 5. Whether you decide to take it right after, during the Year 6 winter break, or immediately after graduation is up to you. But be mindful of a couple of considerations:

  • It can take up to 7 weeks to receive your scores back and CaRMS submissions are generally due in mid-to-late November. You need to ensure your scores are available in time as late applications are seldom considered.
  • If you decide to take MCCQE Part 1 later in the year, it should be timed with taking NAC OSCE earlier in the year as doing both simultaneously can be overwhelming.
  • It is anecdotally preferable to have at least the MCCQE Part 1 or USMLE Step 2 CK under your belt before taking the NAC OSCE as the medical knowledge will help tremendously. As such, taking this exam earlier may work out better so that you can take the NAC during the September session of the year you’re applying.

How should I study for it? Unlike the USMLE Step 2 CK, there is very little information and consensus about which study methods work best. Whereas the USMLE Step 2 CK tests almost purely medical knowledge with some ethical content, the MCCQE Part 1 tests lots of ethical principles and Canadian-specific aspects of practicing medicine such as hospital structure, patient referral systems, medico-legal court outcomes, etc. As such, while using a solid question bank that teaches the fundamentals of medicine, like UWorld for Step 2 CK, is very important, it is also crucial to also access Canadian resources. Of these, the most widely used are:

Some people also choose to use Canada QBank. It is advisable to obtain opinions on material from people who have done well on this exam. It is also crucial to use these resources throughout your clinical years so that you’re already familiar with the content come dedicated study time. We also recommend that you augment your studying with a flashcard application called Anki. It is free to download on your computer and you can get it on your phone so that you can do flashcards on-the-go. Watch YouTube video guides on how to use it. It is invaluable to memorizing minutiae. Additionally, you may find some information about this exam on the following notable forums/discussion spaces:

How long do I need to study for it? Because this exam is normally taken by Canadian medical students and most IMGs after they have already matched in a residency program, it has traditionally been a “pass/fail” exam and scores did not impact your chances of matching in a program (for IMGs, only the NAC and MCCEE scores were considered). As such, most Canadian students take 1-2 weeks to study for this exam. HOWEVER, now with the phasing out of the MCCEE and the MCCQE 1 being introduced as a requirement for application to resident programs for IMGs/CSAs, scores will most certainly begin mattering for you as of CaRMS 2020. As such, take a good 4-5 weeks to study thoroughly for it, while slowly going through the AFMC Primer and Public Health and Preventive Medicine in Canada during the year and taking notes.

All IMGs and CSAs must provide proof of language proficiency when they apply for residency in Canada. This can be done in any of the following ways:

  • IELTS — Minimum score of 7 in each component
  • TOEFL – iBT — Score of 93 and at least 24 on speaking section
  • Letter of language proficiency — only if either your entire Primary and Secondary education was done in English OR if your medical school curriculum + patient interaction was primarily in English (this doesn’t count for us because our patients are predominantly Romanian)

Please be aware that not all programs accept all of the above, and you need to check the CaRMS Program Descriptions for the programs where you wish to apply so that you’re prepared.

Unlike the US where you can apply for residency on a visa, most programs only consider applicants who have either a Canadian citizen or hold a Permanent Resident Status (please check with the government of Canada’s website for specifics on these). This is because Canada wants to retain as many of its trained physicians as possible, and because, before starting residency, you have to sign a “Return of Service” contract whereby you agree to work in an underserved area within the province in which you trained for an X number of years. As you may imagine, the latter would raise many visa-related issues.

Some provinces require that you complete additional exams or assessments in order to apply for residency positions. Please check individual provincial criteria for these. Additionally, different specialties within the same province may require additional examinations. A notable example is the CASPer, which is a situational judgement test, akin to a psychological test. In Ontario, some specialties of some programs require it, while others don’t. Meanwhile, in some other provinces all programs require it and in others, none do. Please check with the CaRMS Program Descriptions for the programs where you wish to apply so that you’re prepared.


PART II: Being a Stronger Applicant

The following items are not requirements for application to a residency position, but having them will make you stand out and significantly improve your chances of matching to a program that you like. Programs are generally looking for well-rounded individuals who demonstrate all 7 facets of the Royal College's CanMEDS Framework. The following information should give you some idea of what you can do and where to find these opportunities.

While it is self-explanatory that good USMLE or Canadian exam scores will put you ahead of the competition, exactly how important these are and how impactful they are to your overall application needs some detailing.
In Canada, some provinces (e.g. Ontario) set global cut-offs to around the 70th percentile, and most programs have even higher cut-offs, most of which are set to around the 90th percentile for specialties outside of Family Medicine. As such, if you don’t score better than 90% of applicants on both exams, your application could be automatically filtered out. While this may seem staggering, please consider the fact that programs receive anywhere from 10 to 40 applications PER SPOT and need to be able to efficiently filter desirable candidates.

The importance of involvement in research depends drastically on your goals. If you intend on pursuing an academic career, significant involvement in research will help you stand out. You should also be prepared to talk at length about your involvement in it. Nevertheless, being involved in research is never a negative and doing it will help you tremendously in learning to read and interpret studies, which is a necessary component of practicing evidence-based medicine as a physician. ISOT is currently in discussions with the University on making research more accessible to students and we will keep you updated on the matter. In the meantime, you can spend your summer in the US or Canada doing research experiences at different universities. Obtaining these is less standardized, and so you should do your own search about which institutions take foreign students. Here are some starting points:

This is probably the most important part of your application aside from great exam scores. Most institutions in the US and Canada want to see that you have clinical (i.e. hands-on) exposure to their medical system, and that you have been able to perform well while doing so. As evidence of this, doctors with whom you work while on these rotations may write you a letter of recommendation describing your performance and character. Strong letters of recommendation can often make up for an otherwise lackluster CV, and will boost your chances of getting a great residency position significantly.

What is an elective rotation? In the US and Canada, medical school is 4 years long. Years 1 and 2 are preclinical, like our years 1 to 3. Year 3 is where clinicals begin, and is called the ‘Core Clerkship’ year because medical students rotate through all of the ‘essential’ specialties of medicine. Core clerkships are family medicine, internal medicine, general surgery, neurology, obstetrics & gynecology, psychiatry, and emergency medicine. Afterwards, year 4 is called an ‘Elective’ year because students choose which rotations they want to undertake, and these are 2 to 4 weeks long. For example, surgically-inclined students will take more surgical electives, and internal medicine folks will take more medicine electives. Foreign students can also participate in these electives at host universities and get the chance to be exposed to these medical systems and impress the doctors they work with. This is similar to ERASMUS, but different in that you are doing only one rotation as opposed to a whole semester.

Does the University give us time to do these electives? As of this writing, the University does not officially grant dedicated time to do such electives, and you must do them on your own time. We are in talks with the administration to allow us blocked time to do away electives.

Does an away elective count for school credit? As of this writing, electives do not count for school credit. We are currently in talks with the University to change this policy.

How can I obtain elective rotations? Canadian electives are relatively easier to obtain than in the US because most lack the 'completed core clerkship' requirement. Electives are all applied to via the AFMC Student Portal. There, you can see each institution’s requirements for their rotations and when they have availabilities. You must create an account in order to apply (note: fee of $500 to make account), after which there may be a small fee for attending the elective. We are currently in talks with our University to directly facilitate rotations within other institutions in the US and Canada. Please also bear the following in mind:

  • You have to apply for rotations many months ahead of actually doing them. As such, you should start planning for them during your summer break or at the beginning of the year so that you have all of your documentation in order.
  • Most electives require you to be in year 6, though some allow international students in year 5 to participate as well.

I saw some companies offer electives rotations for a fee. Can’t I just do that? There do exist companies that advertise rotation opportunities in the US and Canada for a substantial fee (sometimes as high as $3,000+ per rotation). However, please be advised that in the VAST MAJORITY of cases, these are simply observerships sold under the guise of an elective. As the name implies, observerships are experiences where students simply observe a doctor while they work, but are not allowed to participate in patient care. This is because you can not participate in patient care as a medical student unless sponsored through a medical school on an official elective. As such, most of these companies pair you up with an attending physician who takes you on as an observer. However, please note the following:

  • The companies that offer these services generally try everything possible to conceal the fact that they are only offering observerships. This may include misleading answers to direct questions about this issue.
  • A letter of recommendation from such an experience can not contain crucial information about your performance because the physician would not have had the opportunity to witness it. In some cases, relevant items on such letters are fabricated, but this is highly unethical and strongly discouraged.
  • Most residency programs do not count observerships or their letters for the aforementioned reason.
  • If you want them, observerships are FREE in most cases. You can apply for them directly through different universities' websites

How many months of North American clinical experience and LoRs do I need? There is no explicit requirement to have electives done in Canada or the US, or to have LoRs from these doctors. However, anecdotally, most people who match to a residency position in Canada have these. Many universities also prefer that you do an elective in your applied specialty specifically at one of their hospitals and apply with a strong LoR from a physician that you worked with. This is seemingly valued more in Canada than in the US because traditionally, Canadian medical students apply to residency without any board exams under their belts (e.g. like the USMLEs in the US), and so the brunt of that weight is transferred to elective rotation choices and the letters you obtain from them.
While actual weightings are not known, you should assume that you need at least one Canadian elective rotation and one LoR from a Canadian doctor if you plan on applying to Canada. Among the LoRs, having one good letter from a well known professor at our university who is in the field that you are applying to is generally considered a plus. Regarding number of total LoRs, most institutions want exactly 3. Please check each program’s description beforehand.
PLEASE NOTE: USA rotations and having good LoRs from there is also a great asset.

This can be medical or non-medical in nature. Many students choose the former as it gives you more opportunities to involve yourself in the medical community and early exposure to clinical medicine. However, both are acceptable and encouraged.

Engaging in experiences where you work as part of a team and take on leadership roles, outside of school, are very important in developing you as a future doctor. We encourage you to involve yourself in such activities not just for the sake of building a strong CV, but especially because it will help you be a better doctor. The following are some examples of such activities:

  • Joining clubs, both within and without the University
  • Working in a leadership position within student organizations
  • Promoting positive change in the University and within institutions in our city

Awards are given to students who demonstrate high achievement within whichever activity they engage. Aside from the title of Valedictorian, awards are unfortunately seldom given by our university or the hospitals in which we rotate. As such, most of these will come from extracurricular activities.

Upon graduation, you will be given a Medical Student Performance Evaluation (MSPE) or Report (MSPR), depending on whether you’re applying to Canada or the US for residency. In this report, there will be mention of your qualities and academic achievements, including in which quartile of performance you are situated. For example, if your grades are in the top 25% of students, you are said to be in the top quartile of your class. Residency programs that you apply to will see this Evaluation/Report, and it is strongly preferred for candidates to be within this top quartile. Grades matter!