Lucy Martinek was 21 years old when she applied to medical school in Canada.
The Alberta native completed her undergraduate studies at the University of Alberta, taking on additional lab work and additional academic opportunities to supplement her application.
Med school, however, wasn't in the books — at least not in Canada.
"I didn't even get one interview that year," said Martinek. "The feedback I got back was that I should pursue a master's or a PhD to make my application stronger."
Not interested in betting several more years of her life on the slight possibility that she'd get in, Martinek assessed her options. She applied to medical school at St. George's University in the Caribbean country of Grenada.
Now 32 and a physician in the U.S., Martinek isn't thinking about coming back home. Even though an estimated 4.5 million Canadians don't have regular access to a doctor, she says she doesn't feel like her country even wants her back.
It's a common feeling among Canadians who study medicine abroad, especially since most Canadians who study in places like the Caribbean often have to jump through many bureaucratic hoops to practise back home — even after spending years earning their degrees.
According to the Association of Faculties of Medicine of Canada, almost 14,000 people applied to med school in Canada last year. Only 2,611 received an offer of admission.
For those students who choose to brave the application process a second or even third time, failing to get into med school means the end of a lifelong dream.
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"You have two choices, let go of your dream ... or you think of another possibility to go to medical school," said Hassan Masri, an Ontario native who studied at the American University of Antigua.
"At that point, the Caribbean becomes an option."
And it's a difficult option.
Caveats and circumstance
Caribbean medical schools are modelled after their Canadian and U.S. counterparts — students even take American and Canadian board exams so they can apply for residencies in both countries. Still, a Caribbean education comes with a number of caveats.
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Tuition in the Caribbean costs an average of $23,000 per term; in Canada, tuition typically costs $6,000 to $26,000. However, once students factor in the cost of travel and residence, attending school in the Caribbean can easily cost $30,000 or more.
Then there's the matter of clinical rotations. In Canada and the U.S., some med students start their clinical rotations within their first year of studies.
'You almost feel alienated by your own country.' - Dr. Lucy Martinek
In the Caribbean, students spend their first two years learning medical theory "on island." Clinical rotations are carried out during the final two years in the U.S.
What really causes anxiety for Canadians who study medicine abroad, however, is how difficult they find it to come back and practise medicine at home.
"You almost feel alienated by your own country," said Martinek. "I've worked hard and I'm good at what I do — why wouldn't the Canadian government want to keep me?"
Practising medicine back in Canada is a matter of studying the right field of medicine, retaking certain medical board exams, and, in some scenarios, having to redo an entire medical degree.
After med school, students still need to pursue a residency — and sometimes even a fellowship — to launch their careers.
Here, Caribbean medical graduates begin to encounter professional hurdles.
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Foreign-educated Canadians are classified by Health Canada as international medical graduates (IMG) and not Canadian medical graduates (CMG).
The Canadian Resident Matching Services (CaRMS), a not-for-profit organization, works with Canada's medical schools and teaching hospitals to match med students with residency programs.
According to Lisa Turiff, the manager of communications for CaRMS, foreign-trained med students who apply to residency programs in Canada aren't separated based on their countries of origin. A Canadian who studied in the Caribbean is treated the same as a German who studied in Germany. They're all classified as IMGs.
This year, roughly 400 IMGs of the approximately 1,800 who applied to Canadian residency programs — including Canadians studying abroad in places like the Caribbean, Ireland, Australia, and the U.K. — landed a spot. That figure includes a portion of IMGs from previous years who were passed over for a Canadian residency.
Would-be residents and fellows must study a medical specialty specified by the Pan-Canadian List of Needed Specialities (PCLNS).
Tammy Jarbeau, senior media relations adviser at Health Canada, says the list is organized by the provinces and territories to determine how many specialist doctors are needed each year.
"This list reflects the evolving pan-Canadian physician workforce planning landscape," said Jarbeau.
If, for example, Ontario determines that it doesn't need anymore chest surgeons one year, the government won't issue statements of need for chest surgery fellowships.
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In fact, Martinek encountered a problem when she chased a minimally invasive surgery fellowship last year.
"That year, the Canadian government was thinking of not sponsoring anyone for a fellowship," said Martinek. "We got them to reconsider [but] they didn't approve my ... fellowship."
Martinek eventually landed a trauma surgery fellowship at Beth Israel Deaconess Medical Center in Boston, Mass., a teaching hospital that is part of Harvard Medical School.
'I don't know why they don't want us.' - Dr. Lucy Martinek
Martinek also feels that most foreign-trained Canadians aren't given any preferential treatment when returning home, which ironically dissuades foreign-trained Canadian doctors from coming back at all.
"I don't know why they don't want us," said Martinek.
Health Canada, the provinces, the Royal College of Physicians and Surgeons of Canada and the provincial physician colleges make clear the steps required for foreign-trained doctors — whether they're Canadian citizens, permanent residents or foreign nationals — to practise in Canada.
For some , it's as simple as verifying their medical degrees and taking specific college licensing exams. For others, it's more complicated.
Farhan Bhanji, associate director of the college, said it's not impossible for foreign-trained doctors to practise in Canada.
"Right now, there are many foreign physicians in Canada."
However, Bhanji also said that the existing policies don't apply to every foreign physician. Foreign-doctors who attended medical schools not recognized by Canada, for example, need to retake certain exams to seek appointment to the college.
Other foreign-trained doctors can receive provisional licenses that allow them to practise under the care of a supervising physician while awaiting the college's licence exams.
'[Why can't] they come up with another way of us getting accreddited?' - Lucy Martinek
"We're stuck with minimal choices," said Martinek.
A lack of returning Canadian doctors is difficult for some provinces like British Columbia and Nova Scotia that have described their lack of doctors as a "crisis." Places like northern Ontario don't fare much better.
Stigma still an issue
Sandra Banner has 35 years of experience matching students to Canadian residencies. Today she works for St. George's University (SGU) as the consultant for university relations in Canada.
Banner says that there are "sweeping generalizations" about the quality of education at schools like SGU.
For instance, people assume that Caribbean-trained doctors bought their degrees or that the quality of medical training they received is inferior to that of their Canadian counterparts.
Banner says that's not true.
Still, Banner wouldn't recommend attending a Caribbean med school over a Canadian one.
"Never. No, no, no. Never," said Banner. "We would never suggest that they choose an international medical school over a Canadian medical school."
The difficulty of going back home is one of the reasons she'd dissuade prospective med students from listing a Caribbean school as their first choice.
However, "if [applicants] are not one of the lucky ones and they are determined to become physicians," Banner recommends a Caribbean school as an alternative.
Not throwing away your shot
Masri is one Canadian who did manage to come home.
He studied at the American University of Antigua and today the 33-year-old critical care physician teaches at the University of Saskatchewan in Saskatoon.
'Giving up because there are limitations is not an option.' - Dr. Hassan Masri
In spite of his success, Masri is quick to mention that he's one of the few Caribbean-educated Canadian physicians he knows who was able to come back.
"Most people do not come back to Canada because of how rigid the rules are," said Masri.
Just like Banner — and all of the other doctors and medical students interviewed for this story — Masri says he wouldn't recommend his school as a first-choice pick for any student.
Instead, it's a second chance to pursue a life-long dream.
"If this is something you want to do ... giving up because there are limitations is not an option," said Masri.
A graphic in a previous version of this story incorrectly gave the percentage of applications accepted by Canadian faculties of medicine as 6.8. In fact, the correct percentage is 18.7.Jul 31, 2017 5:25 PM ET
A previous version of this story incorrectly said 100 of the approximately 1,800 international medical graduates who applied to Canadian residency programs landed a spot. In fact, 411 IMGs were accepted.Aug 01, 2017 3:39 PM ET