As residency beckons, international medical students intent on returning to Canada question how their training compares to Canadian-trained students. There are over 3500 Canadians studying medicine abroad at 80 different medical schools in 30 different countries, with the majority studying in Australia and Europe (within which Ireland hosts the largest portion) (CaRMS, 2010; Barer et al., 2014). Upon completion of core rotations in Ireland, several of the authors completed clerkship rotations in Canada. We didn’t know what to expect. Irish-trained students commonly rely on vague informal commentary from far-removed ‘doctor friends’ and urban legends of repatriated alumni. North American electives are critically important for residency matching. Students are evaluated on their performance and relationships made in this short time are integral to securing a residency position. A post hoc comparison has limited utility for students aiming to prove their readiness upon arrival at these early career-defining rotations. In this paper, we outline a comparison of Internal Medicine Learning Objectives of an Irish medical school (University College Cork) and CanMEDs Clerkship Curriculum Objectives for a Canadian medical school (University of Toronto) for the specialty of Internal Medicine (Table 1). We subsequently provide a subjective experiential comparison by way of personal observation. We hope this narrative may interest our student successors in Ireland and International Medical Graduates (IMGs) hoping to pursue residency in Canada.

Upon review of Learning Objectives, major differences were not identified in curricula for pathophysiology, clinical medicine, and physical examination skills (Table 1)(University College Cork School of Medicine, 2018; University of Toronto Faculty of Medicine, 2018). The majority of identifiable differences were in areas relating to law, epidemiology, and public health. Irish trainees do not receive training on Canadian health policy or risk factors unique to Canadian populations. Some examples include: differences in responsibility for end-of-life decision-making and code status (these decisions are made by the patient or substitute decision maker in Canada, but by the most responsible physician in Ireland) (Medical Council of Ireland, 2017), epidemiological differences in disease prevalence (e.g. high rates of celiac disease and cystic fibrosis in Ireland) (Johnston et al., 1997; Farrell, 2008), and other socio-medical issues such as healthcare access for specific populations including the First Nations, Inuit, and Métis peoples in Canada and Travelling Community in Ireland (Harfield et al., 2015; O'Donnell et al., 2016).

Clerkship in Ireland

A clerkship day in Ireland typically includes: 1-2 group-based tutorials, 1 hour of bedside teaching, a team ward round, and histories/physical examinations on 2-3 patients. Patient interactions are commonly limited to patients familiar to the attending physicians or junior doctors. Clerks are expected to present structured histories and examination findings, but these presentations rarely inform decisions around patient care. Constructive criticism and questions about the pathophysiology and management of relevant conditions commonly follow. Each day, clerks see different patients for practice, learning about a breadth of topics and seeing many clinical signs. There is a strong emphasis on bedside teaching where a consultant takes a group of students to patients with known diagnoses. Irish clerks routinely perform basic procedural skills such as phlebotomy and intravenous cannulation, as this is a fundamental function of the junior doctor within the Irish healthcare system. Overnight call is not a requirement, though students can elect to be on-call with their assigned teams.

Clerkship in Canada

In Canada, the clerkship format is different in many ways. Observations are primarily drawn from Clinical Teaching Units (CTUs) and select Internal Medicine subspecialty rotations. A clerkship day in Canada typically includes: 1-2 group-based tutorials, 1-2 hours of structured bedside teaching per week, reviewing active patient issues with the team, direct responsibility for 2-6 patients (numbers vary based on patient volumes and level of training), seeing new undifferentiated patient consultations, and overnight call. Clerks are responsible for following up active patient issues, performing physical exams, reviewing investigations, writing progress notes, and creating management plans, which are reviewed by the team. This format challenges clerks to apply clinical skills, follow the same patients each day, observe the effects of their management, and prompt adjustments as necessary. Overnight call is an expectation of Canadian clerkship where medical students see new consultations from the emergency department and manage overnight issues for their admitted ward patients, overseen by a senior medical resident (PGY2 or PGY3).

While the Medical Councils of both Canada and Ireland have similar expectations for the core competencies of their students and trainees, there are unique aspects of each program. In Ireland, there is a greater focus on the mastery of core skills (including basic procedures) and maximizing breadth of exposure by seeing different patients every day, at the expense of direct patient responsibility. Canadian clerkship is more focused on graduated responsibility through individual patient interactions, formulating management plans, and a greater role on a healthcare team, at the expense of some breadth of exposure.

As globalization continues to universalize the supply of medical graduates, greater emphasis should be placed on understanding transatlantic differences in clerkship curriculums both in terms of education and patient-care responsibilities. Publicizing these differences may also better allow preceptors to evaluate students in the context of their training. Awareness of these differences may allow students and preceptors to better align expectation frameworks, making for an even more positive elective experience for all.

There are many possible explanations for differences in Irish and Canadian clerkship experiences ranging from cultural to practical. The Irish and Canadian medical systems evolved in different ways and developed different medical traditions including the delegation of patient care responsibilities. Canada abolished the rotating internship in the early 1990s whereas the Internship year remains a mandatory component of medical training in Ireland. There is no rush for medical students to assume patient care responsibilities in Ireland as Internship serves as a foundational year, allowing learners to achieve graduated responsibility in patient care. Irish residency programs are also on average longer than their Canadian counterparts. Differences in patient volumes may also account for some differences, but no direct comparisons exist in the literature. Noted differences are unlikely to be specific to Internal Medicine. A more thorough comparison amongst a broader range of specialties is warranted to outline roles and responsibilities for incoming international elective students.