Good Intentions, Poor Results

Medicine draws in people who want to make a positive impact on their communities and the world. This, happily, leads to a good number of active, enthusiastic young individuals putting in a lot of work for others' benefit.

However, with that enthusiasm comes a degree of naivete and, particularly in the generally intelligent, capable group of students considering medicine, perhaps a bit of overconfidence. The combination of these traits has led to more than a few instances of students putting their efforts and resources towards well-intentioned, but ultimately ineffective or even detrimental activities. A fair bit of attention has been paid to one such example, the voluntourism industry.

Faulted not just as way for wealthier students to build their CVs, volunteering abroad has also come under significant scrutiny for providing far more help for students to feel like they're doing something positive than actually helping them to do something positive. Some medical schools are actively discouraging volunteering abroad due to concerns about unequal access to these opportunities, harm to developing countries from voluntourists, and comparative lack of skills development when compared to other extra-curricular activities.

However, I'm noticing a trend of closer-to-home activities that often fall into the same category of well-intentioned but ineffectual efforts to help out others. I'm talking about becoming a "founder". Often this takes the form of a student founding a club or new initiative at their undergrad school, or striking out in the community and founding a non-profit.

Just as with volunteering abroad, these are not inherently bad activities - approached properly, by the right individuals with a long-term focus, founding a club or non-profit can be an enormously enriching endeavour, both for the community and the individuals involved. However, as with voluntourism, the typical execution is far from ideal. Student founders often lack either the skill or experience to make their new organizations effective. They may not have the time to give their project the necessary attention. New clubs or non-profits may be trying to fill roles in the community already ably filled by established organizations. Or, they might be trying to fill a role that doesn't really need filling in the first place, resulting in wasted or inefficiently used resources.

I also see clubs or non-profits being started, but then fizzling as the founders transition to other activities. Those founders may have done a fine job with the organization initially, but without a long-term approach in mind or even without a decent transition plan, the next set of leaders may not be properly equipped or motivated to maintain or grow the organization. These groups then hang around in the background, consuming resources ineffectively, before ultimately fading out.

This is hardly an issue unique to students. Heck, entire charitable sectors operate off of good intentions with poor results - this is a very common, very human failing. I'm not immune to it either - a club I helped start at my school just last year looks like it could well end up folding before I even graduate, since we failed to develop enough interest in the classes below us.

Because of these outcomes, I want to encourage students trying to contribute to their community/country/world to consider joining and improving existing organizations first. Take over a club and push it forward. Volunteer at a non-profit and make it better. Get on the inside where you can lobby charities to be more efficient and more evidence-based in their work. And learn what they do right! These experiences within established institutions can be extraordinarily valuable in a student's future career, including for those who ultimately decide further down the road that it's worth starting a new group. Improving what already exists isn't as exciting as starting something new, but in many cases, it can be more meaningful for both students and communities.

If I Don't Study Medicine Abroad, What Are My Options?

As I said in a previous post, studying medicine abroad is a risky proposition - it's quite expensive and has a rather high chance of failure. Yet, students often pursue that route because they feel like there's no other option to becoming a physician - they can't get into a Canadian medical school, so that's the next best thing. However, there are alternatives! Here they are, with some pros and cons to each, in no particular order:

Doctor of Osteopathy (DO) Programs in the United States

Pros: DOs are essentially equivalent to MDs in the US. Their training is essentially the same as it is for MDs, with a bit of a higher focus on primary care and a holistic approach to patient care. They have their own residency programs in the US - which they can fairly easily match into - and they're now eligible for MD residency programs in the US as well. Getting into a DO program is easier than pretty much any Canadian MD school. There are a few DO programs specifically interested in Canadian students.

Cons: Their programs are expensive for Canadians and any loans would require a cosigner. While DO programs have lower entrance requirements than Canadian MD programs, they still have standards and a reasonably competitive application process, so they're not an option for everyone. Obtaining a residency in Canada is subject to some odd province-to-province inconsistencies and generally not much easier than it is for CSAs and some programs are completely off the table. The main difference between DO and MD programs is training in osteopathic manipulative medicine (OMM), which is widely regarded as ineffective by non-DOs (and by more than a few DOs as well). Due to OMM and lower entrance standards, there is still a bit of a stigma against DOs in the US and Canada. DOs will be subject to the new J1 visa restrictions in the US, meaning opportunities to do residency in the US may be somewhat more challenging.

Summary: The DO route for Canadian students is, in many ways, like CSA-light. It shares many of the upfront costs in terms of money and moving to another country, and the chances of doing a residency in Canada aren't much better than the CSA pathway. However, with virtually no difficulties getting a US residency position, the chances of outright failure are low. The incoming visa restrictions complicate this somewhat, but there is always the option to go for an H1-B visa (one sponsored by the residency program rather than by Canada, as is the case with J1 visas), which is much more plausible as a US DO graduate than as an IMG without any connection to the US. A decent fit for some people, but proceed with caution and be realistic about likely outcomes.


MD Programs in the United States

Pros: About as close as you can get to going to a Canadian medical school without actually attending one! USMD programs are accredited by the same organization Canadian schools are, and USMD graduates are considered identical to Canadian grads when it comes to the CaRMS match. High-quality training is guaranteed, the chances of coming back to Canada to do residency are relatively good, and there is ample opportunity to do residency in the US.

Cons: Still quite expensive to attend and still requires a move away from home. If a residency in the US is pursued, all those new visa issues will still apply, though USMDs are in the best position to get an H1-B visa. Entrance requirements are different than most Canadian medical schools, but still at about the same level - there aren't that many people who have no shot at Canadian schools but could easily secure a US MD position.

Summary: If you can finance a US MD and are willing to live at least 4 years outside of Canada, this is the best option, by far. High chance of a good outcome, with low chance of true failure. There are some regulatory complexities that are worth being aware of and Canadians in US MD programs probably have to work a bit harder to keep themselves competitive than Canadian MDs do, but the outlook for both is about the same.


Improve Your Application to Canadian Medical Schools

Pros: No one is ever, 100% out of the running for Canadian medical school admissions. Low GPAs can be overcome with short (2-3 year) second undergrads, or in some cases, a single extra year. Grad school is also an option for some applicants. The MCAT can be rewritten. ECs can be improved. You can add knowledge, skills, and contacts that can be of use in your career as a physician, should you get into a Canadian school. You can (and should) develop an alternative career while simultaneously improving your medical school application. Done right, this pathway takes nothing off the table in terms of your future career prospects and might open up some new ones. You can also stay in Canada.

Cons: Time. Money (though not nearly as much as the other options). It can feel like you're moving sideways rather than forward, even when you are moving forward. To get into a Canadian school, you'll have to do well at something that you previously weren't that great at, so there is a real possibility you won't succeed in becoming a physician.

Summary: This is the humble option. It requires admitting that you might not be ready for medical school - yet. It's the pathway with arguably the highest upside - being a physician in Canada without ever having to leave the country. The downside at first seems pretty bad - if you don't get into a Canadian school, you don't get to be a physician - but unlike the CSA path (and to a lesser extent, the DO and USMD paths), if it doesn't work out the consequences are fairly minor. You won't have nearly as much crippling debt to deal with. An alternative career should already be in development if you don't get into medicine, which makes it easy to go onto other pursuits - CSAs can't easily develop a back-up career in case they don't get a residency.

Everyone, and I mean everyone, has more than one career that would make them happy - even if medicine is your calling, you probably have dozens of other callings! While going the CSA route is risky, this option is safe, but it requires some patience and humility. There are worse traits for aspiring physicians to have in abundance.


Conclusion
To wrap things up, I generally advise people not to study medicine abroad, because I find any of the three options listed above to be preferable. I don't see any reason to pursue medicine outside of Canada or the US if either DO schools or USMD schools are possibilities. Choosing to improve one's chances at Canadian schools instead of studying medicine abroad is a bit more of a judgment call. I see the risk of studying abroad as unacceptably high, while the possibility of pursuing a career outside of medicine is, to me, perfectly acceptable (even though I'm quite happy with the path that I'm on). Those with a different tolerance for risk or a different definition of what they consider an acceptable career path might disagree and choose the CSA route.

The point is that there are always options and that they should be explored fully before making a final decision. I was at a hotel recently where international medical schools were holding an event to recruit Canadian students. The event was hosted by people who were essentially salesmen. Their goal is to get students' money, not to look out for their best interests. Again, for some people, the CSA route may be the best choice according to their values and personal preferences, but too many go abroad misinformed and wind up disappointed.