International medical students are urging a re-evaluation of an in-person exam that would force them to fly to Canada during the pandemic.

The exam, called the National Assessment Collaboration (NAC), is scheduled for Sept. 12 and 13. It is a requirement for international medical graduates who plan to apply to residency in Canada. The exam “includes a series of stations where candidates are presented with typical clinical scenarios using in-person simulations,” according to the Medical Council of Canada (MCC), and is used by residency programs to screen and select international medical students for training. 

Even though the physical part of the examination to assess clinical skills has been cancelled, candidates must still attend in-person to describe verbally what they would do in various clinical situations. The exam is also held in March every year, but writing it then makes it too late for students to apply to residency, which will be in February 2021 because of the pandemic.

HuffPost Canada spoke to several students who are concerned about booking last-minute flights not knowing whether test centres will be open and worried about missing so much school because of the required quarantine periods that they won’t be able to graduate.

“Ultimately, international medical students, whether residing in Canada or abroad, are being forced to accept an increased risk of exposure to COVID-19 by participating in the NAC examination,” according to an open letter written by two students sent to the deans of Canadian medical schools, and shared with HuffPost.

Over 900 people have signed a petition asking for the exam to be moved to a future date, changed to an online format or cancelled altogether. 

“The MCC understands that travel during the pandemic is especially challenging, however our stakeholders have encouraged us to continue with administration of our exams despite the uncertainty,” Dr. Maureen Topps, the MCC’s Executive Director and CEO, said in an email to HuffPost. 

“We are actively encouraging candidates to select exam locations close to their current address due to travel restrictions, and to pay close attention to public health announcements.” 

There are 10 test centres in major Canadian cities, including Toronto, Montreal, Vancouver, Calgary and Winnipeg.

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Over 1,400 students have registered to take the exam so far, and the council is offering refunds to students unable to take the exam because of the pandemic. A “significant portion” of candidates are typically in Canada before writing the exam, Topps said. 

On the MCC’s website, the council says it will “make every effort” to offer students an alternate time and location to take the exam if a second wave of COVID-19 prevents them from attending the exam. 

A spokesperson for the Canadian Resident Matching Service declined to comment.

Graduating medical students in Canada previously told HuffPost about their concerns with writing an online licensing exam also required by the MCC, including not taking breaks to eat, drink or use the bathroom during the lengthy exam for fear of being disconnected by the system. The MCC has said it will conduct a review of the exam season. 

Exam could be cancelled up to the day of writing

The MCC says on its website that the NAC exam could be cancelled for reasons out of its control right up to the day of the exam, and that students should pay attention to local travel advisories. Physical distancing and other protective measures will be put in place at exam centres in accordance with local public health guidelines, the MCC says. 

Students note in the open letter that the exam could coincide with the predicted second wave of the COVID-19 pandemic in Canada. The two weeks of isolation required upon entering Canada — and the two weeks of isolation upon returning to the country they’re studying in — would cost students a month of lost rotations, which they’re supposed to be doing at their international school in the fall, and potentially mean students risk not being able to graduate. (International medical graduates are typically able to take a few days off to fly to Canada, complete the exam and fly back.)

But if students don’t do the exam, they’ll be “effectively withdraw[ing]” from a chance to be matched as a resident in 2021, according to the letter.

It would also be challenging to book last-minute flights with current limited flight schedules and find safe accommodations upon arriving in Canada, students say in the letter.

Students add that the American licensing board for international medical graduates (IMG) suspended its clinical skills exam for 12-18 months because of the risk it would pose to students. The board outlined different ways for applicants to be verified if they’re licensed to practise in another country, like if they’ve passed a different standardized clinical skills exam or attend an accredited medical school where an official can attest to their skills. 

“It should be possible for Canada to develop similar alternative pathways,” the letter reads.

Students don’t feel safe planning to fly in September 

A Canadian medical student studying in Dublin, Ireland, who helped write the open letter, told HuffPost she has the exam booked but is waiting to book her flight until she’s more confident the test won’t be cancelled. She said she doesn’t feel safe flying, given that some airlines have stopped physical distancing on planes.

The student asked to remain anonymous because she fears speaking about the exam could compromise her residency applications. 

Even if she was in Canada, she said she wouldn’t feel safe going to a test centre to take the exam, because there’s no guarantee her fellow students would have quarantined after their international flights. 

It’s concerning that students will be flying into Canada and potentially putting others at risk just to take an exam, she said. “People are flying internationally to come to certain communities to [take] an exam that is very, very unnecessary.”

She said students are also concerned about the scores. Typically they are given number grades, but this year the test will be marked by three categories: fail, pass and pass with superior performance — which the student worries won’t be helpful to the program directors reviewing residency applications.

One doctor planning to apply to residency in Canada in 2021 said she’s in a “big dilemma” about international travel. She is a Canadian citizen working in Australia, where she completed her medical training. She said if she flies into Canada, she’s not sure she’d be able to return to Australia because of the travel restrictions there

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The two-week quarantine in both countries would also amount to missing a month of work. Because the MCC has said the exam can be cancelled at any point, planning travel is a “nightmare,” she said. 

Some students choosing not to come to Canada

Another Canadian student attending school in Dublin who helped write the petition told HuffPost that many of her friends, top students in their classes, are simply choosing not to take the exam and not apply to do their residency in Canada. She also asked not to be identified out of fear that speaking out could impact her residency options.

“These are amazing, qualified students, and they’re all planning to go to the U.S. instead,” she said. 

That student has been in Canada since March, and plans to stay to do the exam in September before flying back to Ireland. By the time she’s quarantined for two weeks there, she’ll have missed about a month of her clinical rotations. Her school has made a contingency plan for students like her, to allow them to make up those four weeks in January. 

But she would have otherwise been doing her elective rotations at hospitals in Canada in January, to gather reference letters to support her residency application. 

She described it as a Catch-22, trying to decide between being at school in Dublin to graduate, or writing the exam in Canada to apply to residency. It’s a “horrible feeling” to be caught between both, the student said.

International medical graduates knew to expect challenges, like additional exams and a greater financial burden. But this situation has been overwhelming, she said. 

“I am a Canadian citizen, so I feel like I have the right to pursue training and job opportunities in my home country, but it’s just impossible at this point,” the student said. 

Dr. Tooba Ali is a physician in Oshawa, Ont. who went to medical school in Pakistan. She said Canada relies on IMGs like herself because we don’t have enough physicians graduating from domestic medical schools to meet the needs of underserved, often rural, areas. 

It’s unfair to international students to go ahead with the exam, she told HuffPost.

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“Obviously we want to make sure that the doctors entering the workforce are trained and safe for Canadians, but there are many different ways to set up those checks and balances,” Ali said. 

She said the alternatives that students have suggested, like holding an online exam or getting a doctor at a student’s international school to vouch for their clinical skills, are valid options that should be considered because of the unprecedented pandemic circumstances. 

Ali said she also worries that the decision to go ahead with the exam will disadvantage students who are immigrants and not Canadian citizens studying abroad, or students who can’t afford the cost of last-minute travel or accommodations. 

“They’re more barriers that they’re sending against [international students] so I really hope that somehow the Medical Council of Canada can think of more creative ways [to hold the exam].”