Doctors in the US and Canada: Two Routes, Two Very Different Bargains (2026)

Two systems, two bargains

For an internationally trained doctor, North America offers a stark choice. The United States runs a centralised, exam-driven system with one route in — and that route means repeating residency, whatever your seniority at home. Canada runs a decentralised system where the main route also means residency, but with a second door: practice-ready assessment, which lets experienced doctors skip it.

Put plainly: the US pays more and asks you to start again. Canada pays less and, for the right candidate, does not.

The US: ECFMG, USMLE and the Match

Every international medical graduate needs ECFMG certification before entering an accredited residency programme. That requires a degree from a medical school in the World Directory of Medical Schools, passes in USMLE Step 1 and Step 2 CK, and completion of one of ECFMG's Pathways verifying clinical and communication skills.

With certification in hand you enter the NRMP Match through ERAS, rank programmes, and find out in March whether you matched. More than 9,000 international graduates matched in a recent year, over a quarter of all matched applicants — the route is well travelled, but competitive, and unmatched applicants often reapply with US clinical experience behind them.

Most IMGs train on a J-1 visa sponsored by ECFMG, which carries a two-year home residency requirement afterwards unless waived — commonly by working in an underserved area. Some programmes sponsor H-1B instead, which avoids the home residency requirement but is harder to secure.

Canada: CaRMS, or practice-ready assessment

Canada's main residency route runs through CaRMS, the R-1 match, with the Medical Council of Canada Qualifying Examination Part I and the NAC OSCE as the entry exams. The constraint that catches people is not the exams: applicants generally need to be Canadian citizens or permanent residents to enter the R-1 match, and IMG residency positions are ring-fenced and few.

The second door is what makes Canada interesting. Practice Ready Assessment programmes, run by several provinces, let experienced family physicians and some specialists enter supervised practice — typically six to twelve months — and then practise independently, without repeating residency. Places are limited, competitive, and usually come with a return-of-service commitment to an underserved community for two to three years.

Immigration runs separately, and healthcare occupations including physicians are targeted in Express Entry category-based draws, which is how many doctors secure the permanent residence that the R-1 match requires.

Who suits what

• Recent graduate, no specialty training: the US Match is the more open door. Canada's IMG residency places are scarce and usually need residency status first.
• Experienced family physician or GP: Canada's practice-ready assessment is the only route in North America that values your existing practice rather than asking you to repeat it. Expect a rural commitment.
• Experienced specialist: check whether your specialty has a PRA route in any province; if not, both countries mean residency, and the US Match is the larger pool.
• UK or Irish trained: compare both against Australia before committing. Australia's expedited specialist pathway grants specialist registration with no college assessment and around six months of supervision — considerably faster than either North American route.

Exams, side by side

United States: USMLE Step 1 (pass/fail), Step 2 CK, an ECFMG Pathway, and Step 3 usually during residency. Certification must be complete before the Match's rank order deadline in February.

Canada: MCCQE Part I and the NAC OSCE for the residency route; PRA programmes set their own assessment, typically a clinical field assessment rather than a written exam. Credential verification runs through ECFMG's service in both countries, so the verification work is not duplicated.

Money and time

Both routes take years rather than months. Budget two to four years from starting exam preparation to independent practice in the US, including residency; Canada's PRA route can be considerably shorter for an established family physician, and its residency route is comparable to the American one. Exam fees, application services, travel for interviews and living costs during unpaid observerships add up — the US route in particular is expensive before it pays.

The honest summary

If you are early in your career and want the widest range of training options, the US is the stronger bet despite the cost and the visa complications. If you are an established family physician willing to work where you are needed, Canada offers something the US simply does not: a route that recognises the practice you already have. And if you hold UK, Irish or New Zealand specialist qualifications, look hard at Australia before either.

Frequently asked questions