I am a dual Canadian / US citizen. I'm an MD. I've never worked in Canada, but I did apply to schools in both countries (back in the stone age). Got rejected from McGill, got accepted to Columbia P&S. So, taking each item in turn:
1) It is definitely more difficult to get into a Canadian medical school. Even for a Canadian citizen.
2) Criteria for acceptance to Medical schools do not translate into clinical competence.
3) Good training and good clinical base is more likely to result into clinical competence.
4) Top medical schools are likely to attract candidates with more intellectual capital who are more likely to withstand a more intensive training regimen, yet maintain some intellectual breadth to continue to expand on this indoctrination (because most of medical training is in fact dogma).
5) Actual quality of a physician, it could be argued, has nothing to do with any of the above. Outcomes, number one, and patient perception, number two, are the only defensible measures of quality. Outcomes, in turn, are determined by surprisingly pedestrian factors. Such as, do you overcommit? Do you show up in the middle of the night, if your patient is crashing? Are you "on" all the time, or do you just coast through your shifts? Does your hubris make you do things and take risks you shouldn't? And, most important, do you have the emotional stability to consistently make good decisions, even when your wife's lawyer is calling you to sign the divorce papers? And reputation has nothing to do with clinical outcomes; some are very good at politics and self-promotion (part of which is placing oneself into a prominent position), yet are terrible clinicians. Academics are notorious for this duality.
However, the more immediate concern of an applicant is a) getting into med school and b) what that med school will do for the career. I have formal training in internal medicine, cardiology, orthopedic surgery and anesthesiology, so I have quite a bit of basis of comparison. I have also done very well financially (mostly from outside activities) and have seen a very high volume of patients through the years (about 140k outpatient encounters and 45k inpatient encounters, with over 14k admissions). I've worked in over 60 hospitals, carried licenses in 6 states and worked in several specialties. Based on these numbers, this is my take:
1) Being competent has nothing to do with the med school of origin, nor even the prestige of residencies one gets. The most incompetent folks can be found in places like Harvard, Stanford or Yale. But statistically you're less likely to encounter such folks, because most people get into such places after persevering on the basis of intelligence, rather than just persevering.
2) A medical school's reputation has everything to do with where you'll end up for your residency, but there are few medical schools that can place you outside of their region. This is where, say, Columbia will be different than Podunk U. McGill places graduates worldwide, whereas nobody ain't never heard of UofT or UBC outside of the neighborhood. Ergo, McGill wins. Hands down. No lo contendere.
3) Necessity is the mother of invention. If McGill has LESS resources, it will train BETTER physicians.
4) Med schools tend to produce tunnel-visioned drones who thrive on dogma. Any school that has to cope with language barriers, logistics and financials issues is a little more likely to breed more commonsense people who can cope with the real world, rather than regurgitate articles.
5) Your eventual choice of specialty is purely a function of whom you know. Barring disastrous grades (and even, in my case, with disastrous grades), you're more likely to get into a residency if you know the program director personally, then an AOA student who is just shopping around. You put in a couple of years of research, and a mediocre student can get a neurosurgery spot. Won't be Mass Gen, but it might be Baylor.
6) People work very hard for status, but nobody outside of medicine knows **** about the difference between rehab or neurosurgery. We're all MDs as far as they are concerned. A specialty that costs you eight years better pay you twice what a three year one does; by the time you're done with your residency in neurosurgery, the schmuck family practice resident has already paid off his/her loans and has put away a million. That's kind of hard to catch up with.
7) Some of the most status-y jobs pay crap; conversely, a lot of community docs in podunk towns make bank. Medicine is about making a living, and doing it by helping people. I posit you're less likely to do a good job and you're more likely to be ethically challenged if you see your first real paycheck at forty, versus thirty. You're more idealistic, you have more choices and you have more time when you're younger. So wasting your time trying to do something because it's "better" in the eyes of others will just end you up in trouble. You'll get frustrated and regret your decision.
8) The more diversity you experience, the easier it is to walk away from a ****ty job. Yes, a rolling stone gathers no moss, but it doesn't gather ****, either. Sticking around at all cost will force you to compromise your ethics and principles, which translates into bad patient outcomes. Your patient might not appreciate it, but I couldn't even begin to estimate the number of people ruined by the practice of medicine because they placed comfort ahead of ethics.
9) Diversity (training in many fields) and volume are the source of true knowledge. You might not be a rocket scientist, but if you can cut it's easier to place a central line than if you can't. You can stop bleeding. The patient you're coding is more likely to survive. But understanding what you're doing is also very important. But skill without cognition is likely to get you into trouble in the long run. Which means, your patient will suffer the consequences.
10) Conversely, no patient has ever been saved by an article. There is a reason why lab techs are not MDs and that's because no amount of knowledge guarantees that you can stand your ground when the **** hits the fan. by the time you finish your training you'll be able to manage a patient while asleep (this is no exaggeration; I am a nocturnist and have given many orders while effectively asleep, yet upon review they are absolutely appropriate and accurate).
This is where, ten years down the road, comes the equalizer. Program directors in the real world know that it makes no difference where you went to school, or how famous your residence is, if you pee your pants when there is a crisis. They want grunts who can do the work, not prima donnas. So any place you go to is ok, as long as you do a good job, you persevere, you keep your cool and THINK STRATEGICALLY. In other words, lay the groundwork for the next step, and then the next, and then the next - ahead of your peers.
At the same time, you'll find that in the end the path of least resistance is usually the best. Stop obsessing so much about where you ended up in the long term; if you're really determined, you'll end up where you want - or where you belong, if your wants are wildly unrealistic - anyway. And you won't torture yourself in the process trying to end up somewhere you shouldn't.
Good luck. I remember my time trying to make decisions as the worst of my life. I wasted far too much time thinking about these things; it ended up working out in its own way in the end. Different than my expectations, but in many ways far better.
Take care, all.
