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2 Production of this report has been made possible through a financial contribution from Health Canada. The views expressed herein do not necessarily represent the views of Health Canada. Project team: Sandra Banner, team leader and site visitor; Ashley McKiver, project manager and researcher; Sara Rattanasithy, data analyst; Josephine Cassie, site visit collaborator; Christel Woodward, survey tool consultant; Rebecca Ford, editor.

3 TABLE OF CONTENTS BACKGROUND... 5 EXECUTIVE SUMMARY... 6 SUMMARY OF RESULTS... 7 RESULTS... 8 SAMPLE... 8 Table 1 Breakdown of 2010 sample by region... 8 Table 2 Medical school of respondents... 8 DEMOGRAPHIC INFORMATION... 9 Figure 1 Age by medical school region... 9 Figure 2 Age: CSA vs. CMG Figure 3 Gender by medical school region Figure and 2006 gender and age comparison Figure 5 Gender comparison: CSA vs. CMG MARITAL STATUS Figure 6 Marital status by medical school region Figure 7 Marital status by gender Figure 8 Marital status: CSA vs. CMG CSAs WITH PARENTS AS PHYSICIANS Figure 9 CSAs with one or more parents who are physicians Figure 10 CSAs with parents who are physicians by region Comparison of the 2010 CSA study to the 2010 Canadian medical graduate cohort PRE-MEDICAL EDUCATION Figure 11 Province of residence before moving abroad Projected number of CSAs by province Figure 12 Comparing province of residence of survey respondents to provincial medical school admission rates and provincial baseline statistics CANADIAN POST-SECONDARY EDUCATION Table 3 Top five reported post-secondary schools attended by CSAs Figure 13 Post-secondary education in Canada by medical school region Figure 14 Highest level of education prior to attending a medical school abroad Highest level of education by medical school region Figure 15 Highest level of education prior to attending medical school: CSA vs. CMG Figure 16 Number of times CSAs applied to Canadian medical schools prior to studying medicine abroad Figure 17 Number of times CSAs applied to Canadian medical schools prior to studying medicine abroad by region Comparison of the 2010 CSA study to the 2010 Canadian medical graduate cohort STUDYING MEDICINE ABROAD Figure 18 Motivation to study medicine abroad Figure 19 Criteria for choosing a medical school abroad Figure 20 How CSAs learned about medical school abroad Figure 21 Year of graduation from medical school Figure 22 Year of graduation by medical school region Figure 23 Satisfaction with medical degree program Figure 24 Satisfaction with medical degree program by medical school region CLERKSHIPS Figure 25 Difficulty in arranging a clerkship rotation in Canada by medical school region Figure 26 Number of clerkship rotations done or confirmed in Canada by medical school region Comparison of the 2006 pilot CSA study to the 2010 CSA study.. 22 FUNDING Table 4 Most popular funding types for medical school abroad Figure 27 Most popular funding types by medical school region Table 5 Top funding source by region and medical school DEBT Estimated total amount of debt Figure 28 Median debt by medical school region Comparison of the 2010 CSA study to the 2010 Canadian medical graduate cohort Figure 29 Satisfaction with cost of medical education Figure 30 Satisfaction with cost of medical education by medical school region Table 6 Annual tuition rates POSTGRADUATE PLANS Figure 31 Intention to return to Canada to pursue postgraduate medical training Figure 32 Intention to stay in Canada to practice medicine after Canadian postgraduate training Table 7 Year of graduation from medical school by intention to return to Canada to pursue postgraduate medical training Table 8 Region of medical school by intention to return to Canada to pursue postgraduate medical training Comparison of the 2006 pilot CSA study to the 2010 CSA study FIRST/TOP CHOICES Table 9 Intending to return for postgraduate training in Canada: first choice locations for postgraduate medical training in Canada Table 10 Intending to return to postgraduate training in Canada: top choice disciplines for postgraduate medical training in Canada Comparison of the 2006 pilot CSA study to the 2010 CSA study Table 11 Top five locations for postgraduate medical training in Canada (CSA vs. CMG) Table 12 Top five disciplines for postgraduate medical training in Canada (CSA vs. CMG) CANADIANS NOT INTENDING TO RETURN TO CANADA FOR POSTGRADUATE MEDICAL TRAINING Figure 33 Perceived barriers to returning to Canada for postgraduate training

4 Table 13 Reasons for not intending to return to Canada for postgraduate medical training by region Figure 34 Country (if not Canada) where CSAs intend to complete their postgraduate medical training Figure 35 Intention to return to Canada to practice medicine after postgraduate medical training abroad Figure 36 Perceived barriers to returning to Canada to practice medicine after postgraduate medical training abroad Comparison of the 2006 pilot CSA study to the 2010 CSA study INTERNATIONAL MEDICAL SCHOOL DATA BY MEDICAL SCHOOL CARIBBEAN Table 14 Caribbean medical school data website sources Table 15 Number of CSAs studying medicine in the Caribbean Table 16 General information Table 17 Admissions by medical school Table 18 Curriculum summary by medical school Table 19 Accreditation by medical school Table 20 Tuition by medical school Table 21 Clerkships by medical school AUSTRALIA Table 22 Australian medical school data website sources Table 23 Number of CSAs studying medicine in Australia Table 24 General information Table 25 Admissions by medical school Table 26 Curriculum summary by medical school Table 27 Accreditation by medical school Table 28 Tuition by medical school Table 29 Clerkships by medical school IRELAND Table 30 Irish medical school data website sources Table 31 Number of CSAs studying medicine in Ireland Table 32 General information Table 33 Admissions by medical school Table 34 Curriculum summary by medical school Table 35 Accreditation by medical school Table 36 Tuition by medical school Table 37 Clerkships by medical school POLAND Table 38 Polish medical school data website sources Table 39 Number of CSAs studying medicine in Poland Table 40 General information Table 41 Admissions by medical school Table 42 Curriculum summary by medical school Table 43 Accreditation by medical school Table 44 Tuition by medical school Table 45 Clerkships by medical school UNITED KINGDOM (UK) Table 46 UK medical school data website sources Table 47 General information Table 48 Admissions by medical school Table 49 Curriculum summary by medical school Table 50 Accreditation by medical school Table 51 Average tuition by medical school Table 52 Clerkships by medical school EUROPE/MIDDLE EAST Table 53 Europe/Middle East medical school data website sources Table 54 Number of CSAs studying medicine in Europe/Middle East Table 55 General information Table 56 Admissions by medical school Table 57 Curriculum summary by medical school Table 58 Accreditation by medical school Table 59 Tuition by medical school Table 60 Clerkships by medical school INTERNATIONAL MEDICAL SCHOOL DATA MEDICAL SCHOOL SURVEY RESULTS SURVEY RESPONDENTS Table 61 Location of survey respondents Table 62 Role of survey respondents MOTIVATION TO RECRUIT INTERNATIONAL MEDICAL STUDENTS REGIONS OF RECRUITMENT Table 63 Factors that influence the number of international students trained Factors that influence the number of international students trained by medical school region Table 64 Intention to change the size of international medical training programs Intention to change the size of international medical training programs by medical school region Table 65 Expected changes in legislation that will impact international medical training programs Expected changes in legislation that will impact international medical training programs by medical school region MEDICAL DEGREE PROGRAMS AND ADMISSION REQUIREMENTS BY MEDICAL SCHOOL REGION Table 66 Available medical degree programs and admission requirements by medical school region Admission procedures Table 67 Additional admission procedures by region of medical school Table 68 Do admissions criteria differ for international students versus national students? Admissions committee Table 69 Admissions committee representatives TUITION Table 70 Average yearly tuition POSTGRADUATE TRAINING REFERENCES APPENDIX ANALYSIS RESULTS

5 BACKGROUND Canada s doctor to patient ratio is among the lowest of any industrialized nation. 1 Despite a 69.0% increase in medical school enrolment, 2 Canadians continue to perceive a doctor shortage. The applicant pool for medical school remains unchanged in the last decade with four qualified applicants for every admitted medical school student in Canada. 2 Over the past decade, and perhaps due to these factors, there has been a recognized and increasing subset of Canadians who have chosen to pursue medical education abroad. Although these Canadians appear to be increasing in number and have begun to have a political voice, little is known about their true numbers, demographics, motivation to study abroad, general characteristics or whether they are interested in returning to Canada. This study was developed to provide a description of this potential resource and to help inform the provincial and federal governments for future physician resource planning. The definition of a Canadian studying abroad (CSA) recognizes that while these individuals are international medical graduates (IMGs), they are Canadians who left Canada to pursue their dream of medical education abroad. They are citizens born in Canada, or permanent residents. Almost all of them have done some of their earlier education in Canada, but choose to go abroad for medical education. This definition separates these individuals from other international physicians (IMGs), who graduate abroad prior to coming to Canada and becoming citizens or permanent residents. The Canadian Resident Matching Service (CaRMS) administers the match into postgraduate training in Canada. CaRMS was the first Canadian medical organization to identify this growing cohort of CSAs seeking entry into the Canadian healthcare system. In Sandra Banner, the Executive Director and CEO of CaRMS, conducted a brief survey of select CSA schools and applicants. This study was based only on informal discussions among some of the international medical schools identified at a point when the medical community estimated that there were approximately 400 students studying medicine outside of North America. The results of this survey estimated that there were approximately 1500 Canadian students studying medicine abroad. 3 Since 2006, the project team has identified additional international schools and an increasing number of CSAs who were used to form the study population for this report. Where possible, the results in this report are compared to data from the 2006 report. CSAs were identified using several data sources including: the CaRMS 2008 and 2009 applicant databases, a list of schools provided by the Medical Council of Canada (MCC), using data from graduates of international institutions applying for MCC s evaluating examination (a prerequisite for residency training in Canada). Using this methodology, 55 schools outside of North America were identified as having Canadian students studying at them. Each school was contacted and asked to distribute a letter to their Canadian students. The letter outlined the scope of the study and provided the online student survey link with password. The online student survey was available from August 2009 through to June Each institution was also asked to complete a school survey and if they were willing to host a site visit. 5

6 EXECUTIVE SUMMARY Canadians studying abroad are spread across the globe from Australia to China to the Netherlands. What they have in common is their desire to come home to Canada to practice medicine. Canadian students who are unsuccessful in being admitted to a Canadian medical school, and make the decision to go abroad to a foreign medical school do so largely because they believe there is a shortage of physicians in Canada, and there will be opportunities for them to return to Canada to practice medicine. While provincial health human resource planning regulates admission to medical schools in Canada, and federal citizenship and immigration regulates the number of immigrants to Canada, there are no regulations that will allow for a prediction of the number of Canadian students who will choose to study medicine abroad and return to Canada for postgraduate training and practice. The number of CSAs has grown exponentially since The estimated number has more than doubled since the first survey in As the majority of Canadians are enrolled in programs with a duration of four years, the output of these international medical schools could contribute almost 700 graduates per year (equal to the total number of graduates each year in all medical schools west of Ontario), or nearly 30% of the total Canadian medical school output. Furthermore, this study indicates that more schools are opening enrolment to international students each year. CSAs are studying medicine in schools all over the world today approximately 80 schools in almost 30 countries are identified as having Canadian students enrolled in medicine. However, most people are only familiar with schools in Ireland, Australia, the Caribbean and most recently, Poland. This study found that every year, new schools are emerging, offering international students the opportunity to study medicine. The majority of these programs target North American students, who are prepared to pay the high tuition fees for the opportunity to become physicians. The medical education they are receiving is as diverse as the countries themselves. There is no typical CSA, as there is no typical immigrant IMG. Both have studied medicine in education systems that have differing curriculums, resources and patient populations. Often, immigrant IMGs have graduated from the same schools that CSAs are graduating from. In countries where the native language is English, international students are integrated into classes with national students. Among the non-profit schools that were visited in this study, international students were valued for their diverse backgrounds, unique perspectives, and as a significant revenue source for the medical school. In some countries, international students are taught in English in a parallel curriculum to the national students who are taught in their native language. International students are given the opportunity to learn the language, but translators are provided during their clinical rotations so that they can experience direct patient contact in the hospitals and clinics. This is the case for schools offering international medical programs to North American students in Poland, the Czech Republic, Romania, Hungary and Bahrain, just to name just a few. Although most schools visited in the study had some sort of national accreditation, it varied considerably from a peer review, to a site visit of the curriculum, to a government-led overall education standard across all of the professional education institutions not specific to medicine. The educational curriculum varied across all schools visited, and the clinical component of the students undergraduate medical education did not usually offer the autonomy and direct patient care of the North American medical education model. Demographically, the majority of CSAs continue to be male, slightly older, single and with more post-secondary education than their medical student counterparts in Canada. CSAs on average have more debt than CMGs CSAs have nearly $90,000 more debt than students in Canadian medical schools, 7 though many cite funding from family savings as a source of support for their education. This study found that more CSAs have a medical doctor as a parent than were identified in a study of Canadian medical graduates (CMGs). 4 The majority of CSAs are residents of British Columbia and Ontario where the success rates of medical school applicants are the lowest. 5 While some students have entered into their international medical school directly from high school, most CSAs have not applied to Canadian medical schools as many times as the successful student studying in Canada. 5 This suggests that due to their age and higher education, CSAs opt to study abroad because they have decided they would not be successful in Canada, or would rather not wait several years to be successful in their Canadian medical school applications. CSAs express frustration in their attempts to arrange Canadian clinical rotations while in their undergraduate years abroad. The inability to obtain clinical experiences during their undergraduate education has increased between the survey in 2006 and 2010, 3 and may result from the increased domestic enrolment and the perceived lack of capacity to provide these experiences to anyone other than Canadians studying in Canada. The Caribbean school respondents reported the most difficulty, while respondents from Australia and Ireland continue to report some success, suggesting that a lack of capacity may not be the entire reason for not obtaining clerkship opportunities. While most CSAs (over 90%) want to return to Canada for postgraduate training, they report frustration with the perceived barriers to pursuing postgraduate education in Canada. These barriers include: choice of discipline, return of service, and the high competition for positions. While Canada has a ubiquitous shortage of family physicians, particularly in rural communities, only 21% of CSAs choose a career in family medicine. However, they have very few, if any, opportunities to complete postgraduate training in the country where they are studying medicine. None of the for-profit schools in the Caribbean have postgraduate training opportunities, and the schools that recruit Canadian students in Ireland, Poland, other European countries and Australia have little or no postgraduate opportunities available for international students. Admission data provided by the schools and the international Canadian student organizations led to an estimation of about 3500 Canadian students enrolled in medical schools abroad. 6

7 SUMMARY OF RESULTS Survey results 32 of the 55 schools (58.2%) agreed to distribute the student survey, 20 (36.4%) answered the institutional survey and 16 (29.1%) agreed to site visits. This represents a four times greater response rate than the original survey in students completed the online survey (approximately a 30.3% response rate, based on estimated enrolment). Students studying in Irish medical schools had the highest response rate (41.8%). The majority of CSAs (46.3%) were found in Caribbean schools. Cohort demographics Overall there was a higher percentage of male students (52.5%) enrolled in international medical schools than males in Canadian medical schools (41.8%). 5 Irish medical schools were the exception, with 57.0% female students, which is similar in composition to Canadian medical schools which average 58.2% female students. 5 Overall, CSAs are older than students in Canadian medical schools, 73.9% of CSAs are years old while only 46.4% of Canadian medical graduates (CMGs) are the same age. 6 A higher percentage of CSAs are single (83.1%) compared to students studying medicine in Canada (61.6%). 6 CSAs were more often children of physicians, with 21.0% reporting one or more of their parents as medical doctors compared to 15.6% of CMGs. 4 CSAs whose parents are physicians were more likely to attend medical school in Ireland. The majority of CSAs come from the provinces of British Columbia and Ontario. Entry into medical school 5.9% of CSAs entered medical school from high school. Despite some CSAs entering medical school directly from high school, more CSAs have advanced degrees than students in Canada, 13.1% of CSAs reported master s degrees, while 9.8% of CMGs reported the same level of education. 5 CSAs applied to Canadian medical schools an average of 1.76 times while CMGs applied 2.59 times before being successful % of CSAs had never applied to a Canadian medical school. The most frequently reported reason for choosing an international medical school was students felt they would be unable to secure a place in a Canadian school. Cost, debt and satisfaction The average annual tuition cost ranges from $12,250(CAD) in Poland to $66,369(CAD) in Australia. Site interviews revealed that international students are important revenue sources for not only the for-profit universities but also the non-profit state universities. In the latter cases, CSAs tuition supplements the national medical education costs. The CSA median debt is $160,000(CAD) compared to the 2007 CMG median debt of $71,000(CAD). 7 CSAs with lower reported median debt reported higher satisfaction with the cost of their medical education. Educational process, choices and perceived barriers to postgraduate education A smaller percentage of respondents in this survey reported success negotiating clinical type clerkship experiences than respondents in the 2006 survey. 3 Respondents from Australia and Ireland were more successful than the respondents from the Caribbean in arranging Canadian clerkships. 90.3% of the respondents reported a desire to return to Canada for a portion of their postgraduate medical education, and 24.8% reported a plan to return to Canada after postgraduate training abroad. Only 67.2% of respondents in the 2006 survey indicated their intention to return to Canada for postgraduate training. 3 In both the 2006 and 2010 surveys, the further away the respondents were from graduation, the more likely they were to respond that they intended to return to Canada. 3 The main barriers cited regarding the return to Canada for postgraduate medical training were: - The requirement to provide return of service for the postgraduate experience. - The choice of discipline was difficult to obtain. - The perception that they would have difficulty matching to a program in Canada. The top two career choices of CSAs continue to be Family Medicine and Internal Medicine, similar to the 2006 survey. 3 The top two university choices were the University of Toronto and the University of British Columbia. Limitations The following limitations have been identified: Respondent bias as analysis has been done on selfreported data. The findings are also subject to non-response bias, as well as low response bias. As an example, it was difficult to compare the Middle East to all other areas surveyed, as the response rate was much smaller. This made it difficult to project any true trends for that area. Non-participation the study was subject to the international medical schools willingness to participate. Without the aid of the schools, it proved to be very difficult to contact and recruit participation of Canadian students. The findings are limited by having little access to Canadian students from the Caribbean medical schools, especially those in their clinical years. Faculty and students likely wanted to present their schools in the best possible light. There was no incentive to complete the surveys. At the beginning of the study, only 55 of the more than 75 schools where Canadians are now known to be studying medicine abroad were identified, as more schools are discovered every day. 7

8 RESULTS SAMPLE Statistical analysis In total, 1082 CSAs completed the survey. From these respondents, a summary of demographic information was conducted, followed by an analysis of pre-medical education, current experience with medical education, and postgraduate plans. The respondents were also grouped according to the geographic region of their medical school to determine if there were notable differences across geographic regions. The Pearson chi-square test of independence was used to look for relationships between variables. Further, differences in proportions were tested using the z-test for proportions. A p value < 0.05 was regarded as being significant. TABLE 1 BREAKDOWN OF 2010 SAMPLE BY REGION Medical School Survey Estimation of CSAs Enrolled in Medical Region Respondents Schools Across all Years of Study Ireland* Poland** Caribbean Australia Middle East*** Totals * Three respondents listed as attending a medical school in the UK were included in this group as there were not enough respondents to create a separate group for analysis. ** Two respondents listed as attending a medical school in the Czech Republic and one survey respondent listed as attending a medical school in Romania were included in this group. ***Middle East group includes respondents attending a medical school in Bahrain and Israel. Note: one respondent was excluded from the regional analysis because they were from an international medical school not contacted for this study, and not within any of the regions contacted. TABLE 2 MEDICAL SCHOOL OF RESPONDENTS 8 Medical School Region n % St. George s University Caribbean % Saba University School of Medicine Caribbean % University of Queensland Australia % Royal College of Surgeons in Ireland Western Europe % University of Sydney Australia % Jagiellonian University Medical College Eastern Europe % Ross University Caribbean % Trinity College, University of Dublin Western Europe % University College Dublin Western Europe % University College Cork Western Europe % University of Limerick Western Europe % Poznan University of Medical Sciences Center Eastern Europe % Flinders University of South Australia Australia % RCSI Bahrain Middle East % Sackler School of Medicine Middle East % University College, Galway Western Europe % American University of the Caribbean School of Medicine Caribbean % Xavier University School of Medicine, Bonaire Caribbean % University of Wollongong Australia 8 0.7% University of Melbourne Australia 7 0.6% James Cook University Australia 6 0.6% Windsor University Caribbean 6 0.6% All Saints University School of Medicine, Dominica Caribbean 3 0.3% Continued on page 9

9 TABLE 2 MEDICAL SCHOOL OF RESPONDENTS Medical School Region n % International American University College of Medicine Caribbean 2 0.2% University of Sint Eustatius Caribbean 1 0.1% Spartan Health Sciences University Caribbean 1 0.1% IAU College of Medicine Caribbean 1 0.1% Medical University of Warsaw Eastern Europe 1 0.1% Medical University of Silesia, School of Medicine in Katowice Eastern Europe 1 0.1% St. Georges University Western Europe 1 0.1% University of Manchester Western Europe 1 0.1% University of Nottingham Western Europe 1 0.1% Other 4 0.4% Total % * Other includes schools in: Chile, Romania, and the Czech Republic DEMOGRAPHIC INFORMATION Age The average age of CSAs is 26 years old, with a range of 18 years old to 46 years old. AGE BY MEDICAL SCHOOL REGION 80% 70% 60% 50% 40% 30% 36.8% 54.4% 30.4% 59.5% 46.7% 43.5% 72.3% 39.1% 60.9% 24 & under & over 20% 10% 0% 10.2% 13.1% 8.1% 8.9% 7.6% 0.7% 1.3% 2.2% 4.4% Ireland Poland Carribean Australia Middle East Figure 1 Age by medical school region When examining the age of CSAs in relation to their region of study, it was found that Australia had a significantly older population than any other region. 9

10 Comparison of the 2010 CSA study to the 2010 Canadian medical graduate cohort AGE COMPARISON 100% 73.9% * Source: CaRMs 2010 CMG Cohort Data 50% 0% 10.6% CSA 14.8% 45.3% 46.4% 7.7% 0.6% 0.6% CMG Figure 2 Age: CSA versus CMG By increasing the age of the CSA respondents to reflect their true age at graduation, they could then be compared to the Canadian medical graduate cohort of It was found that only 10.6% of CSAs are under 25, compared to 45.3% of CMGs. While 91.7% of CMGs are under 30, twice as many CSAs are older than 30. Overall, the CSA cohort is older than the CMG cohort. Gender Overall, males made up 52.5% of the respondents and females accounted for the remaining 47.5%. GENDER BY MEDICAL SCHOOL REGION 60% 50% 40% 43.0% 57.0% 54.4% 45.6% 56.3% 43.7% 55.3% 44.7% 52.2% 47.8% Male Female 30% 20% 10% 0% Ireland Poland Carribean Australia Middle East Figure 3 Gender by medical school region A higher percentage of men studying abroad than women was found in every region surveyed, with the exception of Ireland, where there were 14.0% more women studying medicine than men. 10

11 Comparison of the 2006 pilot CSA study to the 2010 CSA study Gender and age comparison 2010 CSAS: GENDER BY AGE 2006 CSAS: GENDER BY AGE 100% 80% 60% 40% 20% 0% 51.3% 24 & Under 51.5% 48.7% 48.5% 58.9% 41.1% 70.0% & Over 66.7% 30.0% 33.3% 45 & Over Male Female 100% 80% 60% 40% 20% 0% 52.3% 47.7% 24 & Under 55.8% 44.2% 77.3% 22.7% 50.0% & Over 50.0% 100% 0.0% 45 & Over Male Female * Source: CaRMS 2006 CSA Report Figure and 2006 gender and age comparison In the 2006 pilot study, it was found that females were more likely to fall into the youngest age category while males where twice as likely to be 30 years of age or older. However, the 2010 study revealed that no significant differences existed in the age groups when compared by gender. Comparison of the 2010 CSA study to the 2010 Canadian medical graduate cohort Gender comparison GENDER CSA VERSUS CMG 100% 80% 60% 40% 20% 51.3% 51.5% 52.5% 48.7% 48.5% 70.0% 66.7% 58.9% 41.8% 41.1% 30.0% 33.3% Male Female 47.5% 58.2% CSA CMG* * Source: Canadian Medical Education Statistics 2009, The Association of Faculties of Medicine of Canada 0% 0% 24 & Under Male & Over 45 & Over Female Figure 5 Gender comparison: CSA versus CMG It is interesting that the proportions are nearly reversed in the two data sets. More men are studying medicine abroad, while more women are studying medicine in Canada. The only region that is similar in composition to Canada is Ireland, where 57.0% of students studying abroad were women. See the Appendix for full details of analysis results. 11

12 MARITAL STATUS The majority (83.1%) of CSAs are single, separated or divorced, while only 16.9% are married/living with a partner. The majority (81.5%) of CSAs did not have family members or a partner living abroad with them during their medical education. Only 18.5% of CSAs reported having family members or a partner living with them abroad full-time or occasionally during their medical education. MARITAL STATUS BY MEDICAL SCHOOL REGION 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 85.7% 82.3% 85.0% 70.9% 28.2% 91.3% 17.7% 14.3% 14.0% 8.7% 0.0% 0.0% 1.0% 1.0% 0.0% Ireland Poland Carribean Australia Middle East Single Married/Living with a partner Separated/ Divorced Figure 6 Marital status by medical school region Overall, Australia had the highest percent (28.2%) of Canadians studying abroad who were married/living with a partner. This may be a result of these students generally being older. See the Appendix for full details of analysis results. MARITAL STATUS BY GENDER 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 81.5% 83.5% Single 17.8% 16.0% Married/Living with partner 0.7% 0.6% Separated/ Divorced Male Female Figure 7 Marital status by gender This analysis concluded that neither males nor females are more likely to be married/living with a partner while studying abroad. 12

13 Comparison of the 2010 CSA study to the 2010 Canadian medical graduate cohort Marital status comparison MARITAL STATUS: CSA VERSUS CMG 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 83.1% CSA 16.9% CMG 61.6% 38.4% Single/Divorced Separated/Widower Married/Living with partner * Source: CaRMs 2010 CMG Cohort Data Figure 8 Marital Status: CSA versus CMG While only 16.9% of CSAs are married/living with a partner, theopposite trend is true for Canadian medical students, where a significantly greater proportion (38.4%) is married/living with a partner. CSAs WITH PARENTS WHO ARE PHYSICIANS CSAs WITH ONE OR MORE PARENTS WHO ARE PHYSICIANS 79.0% 17.2% 3.8% Yes, one parent Yes, both parents No CSAs WITH ONE OR MORE PARENTS WHO ARE PHYSICIANS BY REGION 90% 84.2% 81.1% 82.6% Yes 80% 77.2% No 70% 68.0% 60% 50% 40% 30% 32.0% 22.8% 20% 10% 15.8% 18.9% 17.4% n=1082 0% Ireland Poland Carribean Australia Middle East Figure 9 CSAs with one or more parents who are physicians Of the 21.0% of CSAs that have one or more parents as a medical doctor, 42.5% are family physicians, while 57.5% are specialists. Figure 10 CSAs with parents who are physicians by region Students who have one or more parents who are physicians are almost twice as likely to choose to study medicine in Europe specifically Ireland rather than the Caribbean. See the Appendix for full details of analysis results. 13

14 Comparison of the 2010 CSA study to the 2010 Canadian medical graduate cohort CSAs with one or more parents who are physicians As reported in the Canadian Medical Association Journal (CMAJ), 15.6% of today s Canadian medical students have a physician parent. 4 In comparison, 21% of CSAs have at least one parent who is a physician. PRE-MEDICAL EDUCATION 1.2% 18.6% 10.5% 1.9% 2.1% PROVINCE OF RESIDENCE BEFORE MOVING ABROAD 0.4% 2.8% 1.1% 3.6% 57.8% NL PE NS NB QC ON MB SK AB BC Figure 11 Province of residence before moving abroad 86.9% of Canadians studying abroad are residents of three of the 10 Canadian provinces, with 57.8% residents of Ontario, 18.6% residents of British Columbia and 10.5% residents of Alberta. Projected number of CSAs by province This survey indicates that there are approximately 3500 Canadian students studying medicine abroad, with as many as 500 coming from British Columbia and over 1500 from Ontario. 70% 60% 50% 40% 30% 20% 10% 0% COMPARING PROVINCE OF RESIDENCE OF SURVEY RESPONDENTS TO PROVINCIAL MEDICAL SCHOOL ADMISSION RATES AND PROVINCIAL POPULATION BASELINE STATISTICS NL PE NS NB QC ON MB SK AB BC Survey respondent s province of residence (%) Success rate of applicants (%) Population baseline** (%) * Source: Canadian Medical Education Statistics 2009, The Association of Faculties of Medicine of Canada ** Source: 2009 Population by Province, Statistics Canada Figure 12 Comparing province of residence of survey respondents to provinical medical school admission rates and provincial baseline statistics This graph shows that Ontario and British Columbia have the greatest population when compared to the other Canadian provinces. They also have the highest number of residents who choose to study medicine abroad. Furthermore, Ontario, British Columbia and Prince Edward Island have the lowest rate of successful medical school applicants. Therefore, the increased frequencies at which Ontario and British Columbia students choose to study medicine abroad may be a direct response to the lower success rates of medical school applicants, and larger population baselines in Ontario and British Columbia. 14

15 CANADIAN POST-SECONDARY EDUCATION Post-secondary education A total of 90.3% of CSAs attended a post-secondary institution in Canada prior to attending an international medical school. The University of Toronto was the most attended Canadian institution for post-secondary education among the survey respondents. TABLE 3 TOP FIVE REPORTED POST-SECONDARY SCHOOLS ATTENDED BY CSAS Post-Secondary School Province n % University of Toronto Ontario % The University of Western Ontario Ontario % The University of British Columbia British Columbia % McMaster University Ontario % McGill University Quebec % 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% POST-SECONDARY EDUCATION IN CANADA BY MEDICAL SCHOOL REGION 93.8% 98.1% 80.5% 83.5% 87.0% 19.5% 16.5% 13.0% 6.2% 1.9% Ireland Poland Carribean Australia Middle East Yes No Figure 13 Post-secondary education in Canada by medical school region Respondents from the Caribbean and Australia where more likely to have attended a post-secondary institution in Canada than those whose medical school was in Europe, where admission to medical school is available directly from high school. HIGHEST LEVEL OF EDUCATION PRIOR TO ATTENDING MEDICAL SCHOOL ABROAD Ph.D., or Equivalent Master s degree Bachelor s degree 3 years or more of university 2 years or less in university Post -secondary High school Other 1.6% 1.9% 2.8% 0.4% 5.9% 0.6% 13.1% 73.7% 0% 10% 20% 30% 40% 50% 60% 70% 80% Figure 14 Highest level of education prior to attending a medical school abroad In 2010, 88.4% of respondents indicated that they had a bachelor s degree, master s degree or Ph.D prior to attending an international medical school. Only 5.9% reported receiving only a high school diploma prior to studying abroad. 15

16 Highest level of education by medical school region When comparing the highest level of education of respondents based on the geographic region of their medical schools, Australian students and Caribbean students were the most likely to have completed a bachelor s degree prior to studying abroad. The proportion of students who had attained master s degrees was the highest in Australia (14.6%), comparable to the Caribbean where 13.4% of respondents had attained master s degrees and Ireland, where 13.6% have a master s. In Poland, just 5.1% of students reported having postgraduate degrees prior to studying abroad. Comparison of the 2010 CSA study to the 2010 Canadian medical graduate cohort HIGHEST LEVEL OF EDUCATION PRIOR TO ATTENDING MEDICAL SCHOOL 80% 70% 60% 50% 40% 30% 20% 10% 0% 5.9% 0.8% 0.4% 14.5% High School College 2.8% 3.7% 2 years or less in university (no degree) 1.9% 7.1% 3 years+ university (no degree) 73.7% 60.9% Bachelor s Degree 13.1% 9.8% 1.6% 2.9% 0.6% 0.3% Master s Degree Ph.D. or equivalent Other CSA CMG * Source: CaRMs 2010 CMG Cohort Data Figure 15 Highest level of education prior to attending medical school: CSA versus CMG Although a greater number of CSAs than CMGs enter medical school directly from high school, CSAs are significantly more educated than CMGs when entering medical school. APPLICATION TO CANADIAN MEDICAL SCHOOLS APPLICATION TO CANADIAN MEDICAL SCHOOLS 40% 35% 30% 25% 20% 15% 10% 5% 0% 26.7% Did not apply 37.0% 23.6% 9.3% 1.9% 0.9% 0.1% 0.1% 0.1% 0.1% 0.1% 0.1% 1x 2x 3x 4x 5x 6x 7x 8x 9x 10x 13x Number of Times Applied Figure 16 Number of times CSAs applied to Canadian medical schools prior to studying medicine abroad. A total of 37.0% of CSAs applied only once to Canadian medical schools, while approximately the same number of CSAs applied two or more times to Canadian medical schools prior to studying abroad. Interestingly, 26.7% did not apply to any Canadian medical schools prior to studying abroad. Of the CSAs that did not apply to any Canadian medical schools before going abroad, there is a significant difference in their highest level of education. For CSAs that had a high school education before going abroad, 95.3% did not apply to any Canadian medical schools, while 20.8% of CSAs with a bachelor s degree did not apply to any Canadian medical schools. See the Appendix for full results. 16

17 APPLICATION TO CANADIAN MEDICAL SCHOOLS BY MEDICAL SCHOOL REGION 60% 50% 40% 30% 20% 38.2% 32.7% 29.0% 54.4% 29.1% 16.5% 23.6% 43.1% 33.3% 49.0% 34.8% 34.8% 31.6% 30.4% 19.4% Did not apply Applied once Applied 2x or more 10% 0% Ireland Poland Carribean Australia Middle East Figure 17 Number of times CSAs applied to Canadian medical schools prior to studying medicine abroad by medical school region Almost half of the respondents from Australia applied multiple times to Canadian medical schools prior to leaving to study medicine abroad. In contrast, 54.4% of the respondents from Poland had never applied to a Canadian medical school prior to deciding to study medicine abroad, 27.9% cited their reason as being able to enter medical school directly from high school, while 20.9% cited that they were unable to gain acceptance into a Canadian medical school. Comparison of the 2010 CSA study to the 2010 Canadian medical graduate cohort Application to Canadian medical schools Canadian students studying medicine abroad on average applied to Canadian medical schools 1.76 times prior to enrolling in a foreign medical school. In contrast, Canadian students studying at Canadian medical schools, on average, apply 2.95 times prior to being admitted. 5 STUDYING MEDICINE ABROAD MOTIVATION TO STUDY MEDICINE ABROAD 80% Unable to obtain a place in a 77.6% Canadian medical school 73.7% 70% Allowed me to enter medical school 60% 7.8% 60.9% directly from secondary school 50% Wanted to live in another country 6.6% 40% 30% Tuition costs were lower than Canadian medical school 1.8% 20% My family was living in this 14.5% 0.5% 13.1% 10% foreign country currently 9.8% 5.9% 0.8% 0.4% 2.8% 3.7% 1.9% 7.1% 1.6% 2.9% 0.6% 0.3% 0% Other 5.8% High School College 2 years or less in 3 years+ university Bachelor s Degree Master s Degree Ph.D. or equivalent Other university 0% 10% (no degree) 20% (no degree) 30% 40% 50% 60% 70% 80% CSA CMG Figure 18 Motivation to study medicine abroad Overall 77.6% of CSAs reported that their main reason for choosing to study abroad was because they were unable to obtain a place in a Canadian medical school. A total of 1.8% reported it was due to lower tuition costs. 17

18 CRITERIA FOR CHOOSING A MEDICAL SCHOOL ABROAD Reputation (n= 1082) Likelihood of obtaining some clerkships in North America (n= 1082) Course taught in a language I understand (n= 1082) 51.1% 77.4% 88.6% * Participants were able to select more than one answer. Cost (n= 1082) 35.6% Attractiveness of country (n= 1082) 32.0% Proximity to Canada (n= 1082)) Other (n= 1082) 8.2% 7.1% Figure 19 Criteria for choosing a medical school abroad 0% 20% 40% 60% 80% 100% Reputation was the most important factor in choosing a medical school abroad, while the opportunity for clerkships in North America came in a close second. This may be an advantage in recruitment strategies of medical schools in the Caribbean, where all of the medical schools make use of hospitals in the US for their clerkship training. HOW CSAs LEARNED ABOUT MEDICAL SCHOOL ABROAD From a friend/relative/graduate from school (n=1082) Searched on internet (n=1082)) Attended the school s presentation in Canada (n=1082)) School s advertisement posted in a university (n=1082) Newspaper/magazine article (n=1082) Other (n=1082)) 6.4% 4.2% 7.4% 18.0% 40.6% 72.7% * Participants were able to select more than one answer. 0% 10% 20% 30% 40% 50% 60% 70% 80% Figure 20 How CSAs learned about medical school abroad The majority (72.7%) of CSAs learned about their medical school from a friend/relative or graduate from the school, while only 18.0% attended the school s presentation in Canada. 18

19 YEAR OF GRADUATION FROM MEDICAL SCHOOL % % % % % % 0% 5% 10% 15% 20% 25% 30% 35% Figure 21 Year of graduation from medical school The vast majority of respondents are in a four year medical program. 72.8% of the respondents will be graduating between 2012 and 2014, which places them in the early years of their medical education. 19.1% are completing five or more years of study. This may reflect the 7.8% who chose a medical school abroad on the basis that they could enter directly from high school. It also speaks to the large proportion who did not apply in Canada at all. YEAR OF GRADUATION BY MEDICAL SCHOOL REGION 50% 45% 40% 35% 30% 25% 32.0% 28.3% 38.0% 25.3% 45.7% 27.2% 29.1% 35.9% 39.1%39.1% % 15% 10% 5% 0% 20.6% 17.6% 16.5% 14.0% 13.9% 11.8% 11.8% 11.2% 8.7% 8.7% 5.3% 4.6% 4.3% 3.8% 2.2% 2.5% 2.4% 0.4% 0.0% 0.0% Ireland Poland Carribean Australia Middle East Figure 22 Year of graduation by medical school region Overall, the Australian respondents were the closest to graduation ( ), while the majority of students in Ireland, Poland, and the Caribbean were further from graduation and expected to graduate between 2012 and The Caribbean had the lowest percent of respondents expected to graduate between 2010 and This may be due to the fact that the third and fourth year students attending medical school in the Caribbean are currently dispersed across the United States doing clerkships. It was difficult to find a clerkship coordinator to notify the clinical clerks about this survey. The exception was St. George s in Grenada, where the clerkship dean assisted in the notification of students. 19

20 SATISFACTION WITH MEDICAL DEGREE PROGRAM 1.9% 5.5% 51.4% 0.6% 40.5% Very Satisfied Satisfied Neutral Dissatisfied Very Dissatisfied Figure 23 Satisfaction with medical degree program Overall, 91.9% of survey respondents reported being satisfied and/or very satisfied with the medical education they are receiving abroad. SATISFACTION WITH MEDICAL DEGREE PROGRAM BY MEDICAL SCHOOL REGION 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 93.4% 92.4% 93.6% 85.9% 87.0% 13.0% 4.4% 6.3% 8.7% 2.2% 1.3% 4.4% 2.0% 5.3% 0.0% Ireland Poland Carribean Australia Middle East Satisfied Neutral Dissatisfied Figure 24 Satisfaction with medical degree program by medical school region Canadians studying in the Caribbean reported being the most satisfied (93.6%) with their medical degree program, while those studying in Ireland were also highly satisfied (93.4%). A total of 92.4% of CSAs in Poland reported overall satisfaction, while 85.9% of CSAs in Australia reported the same satisfaction. Although students studying in Australia tend to be more critical of their medical education, some considerations leading to these results may be that they are older and slightly better educated. Proportionally, the Australian respondents were also further along in their medical education, either in their third or fourth years of study. 20

21 CLERKSHIPS Only 22.6% (n=244) of the respondents were in a clerkship year. Of these respondents, 69.1% (n=168) reported that they had tried to arrange a clerkship rotation in Canada. When surveyed on the difficulty of arranging clerkships in Canada, 55% found it difficult to very difficult, while only 18.6% reported it to be easy or very easy. The remaining respondents were neutral on the matter of arranging a clerkship in Canada. DIFFICULTY IN ARRANGING A CLERKSHIP ROTATION IN CANADA BY MEDICAL SCHOOL REGION 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 82.5% Easy Okay Difficult 44.8% 48.9% 41.7% 26.9% 28.4% 33.3% 25.0% 29.8% 17.5% 21.3% 0.0% Ireland Poland Carribean Australia Figure 25 Difficulty in arranging a clerkship rotation in Canada by medical school region Overall, 82.5% of respondents from the Caribbean reported that it was difficult to arrange a clerkship in Canada. A total of 48.9% of Australian respondents felt the same way. See the Appendix for full details of analysis results. NUMBER OF CLERKSHIP ROTATIONS DONE OR CONFIRMED IN CANADA BY MEDICAL SCHOOL REGION 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 11.0% 9.9% 79.0% 8.9% 3.8% 87.3% 1.4% 1.8% 96.8% 13.6% 6.3% 80.1% 4.3% 0.0% Ireland Poland Carribean Australia Middle East 95.7% Yes, done Yes, confirmed No Figure 26 Number of clerkship rotations done or confirmed in Canada by medical school region A total of 20.9% of CSAs in Ireland reported that they had done or confirmed a clerkship in Canada. A total of 19.9% of CSAs in Australia also reported having done or confirmed a clerkship in Canada, while only 12.7% from Poland, 3.2% from the Caribbean and 4.3% from the Middle East reported having done or confirmed a clerkship in Canada. These numbers are comparable to Figure 25 which shows how difficult it is to arrange a clerkship in Canada. Regions that reported a high difficulty in arranging a clerkship displayed the lowest numbers of clerkships done or arranged in Canada, while regions that reported having done or arranged clerkships in Canada felt they were easier to arrange. This result could be an indication of bias for students in Ireland and Australia over students in other regions. 21

22 Comparison of the 2006 pilot CSA study to the 2010 CSA study Overall, a lower percentage of respondents in 2010 reported having successfully arranged a clerkship in Canada. In 2010, students from Australia reported the most clerkships arranged or completed in Canada, while in 2006, CSAs studying in Europe were the most likely to have completed or arranged a clerkship in Canada. 3 The 2006 and 2010 studies both found that CSAs studying in the Caribbean were the least likely to have completed or arranged a clerkship in Canada. 3 FUNDING TABLE 4 MOST POPULAR FUNDING TYPES FOR MEDICAL SCHOOL ABROAD FUNDING TYPE % Family savings 70.3% Bank loan in Canada 69.1% Government grants Canada 37.6% Personal savings 31.2% Bank loan elsewhere 6.6% International scholarship (study abroad grant) 7.8% Other 6.8% The most popular type of funding for medical school reported by CSAs was family savings, followed by bank loans and government grants in Canada. However, as Table 4 shows, CSAs do not use just one source to fund their medical school abroad, but tend to use a combination of sources. When looking at the average CSA, 44.0% of their total funding to attend an international medical school is from a bank loan, 37.0% is from family savings, and only 1.0% is from an international scholarship. * Survey respondents were able to select more than one answer. MOST POPULAR FUNDING TYPES BY MEDICAL SCHOOL REGION 50% 40% 30% 20% 10% 0% Ireland Poland Carribean Australia Middle East Family Savings Bank Loan in Canada Government Grants Personal Savings International Scholarships Bank Loan Elsewhere Other Figure 27 Most popular funding types by medical school region Family savings was cited as the main funding source more frequently by CSAs in Europe and the Middle East than CSAs in the Caribbean or Australia. A higher percentage of CSAs in Australia and the Caribbean reported that they funded their education through a bank loan in Canada. TABLE 5 TOP FUNDING SOURCE BY REGION AND MEDICAL SCHOOL Region Medical School Top Funding Source % Average Yearly Tuition ($CAD) Ireland Royal College of Surgeons Family Savings 95.2% 63,051 Trinity College, University of Dublin Family Savings 78.3% 41,809 Poland Jagiellonian University Medical College Bank Loan in Canada 66.0% 15,780 Poznan University of Medical Sciences Center Family Savings 70.8% 12,911 Caribbean St. George s University Bank Loan in Canada 74.1% 62,232 Saba University School of Medicine Bank Loan in Canada 79.1% 27,178 Australia University of Queensland Bank Loan in Canada 71.9% 54,571 University of Sydney Family Savings 82.7% 53,112 Middle East RCSI Bahrain Family Savings 83.3% 38,245 Sackler School of Medicine Personal Savings 45.5% 28,644 22

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