What is the NAC?

The National Assessment Collaboration (NAC) examination is a one-day test that is taken by international medical graduates (IMGs) and DO school graduates from the US who are applying to Canadian residency programs. The NAC exam was created to reduce the duplication of previous assessments for IMGs and to standardize the results that are seen by residency program directors across Canadian provinces.

Due to the current situation, the NAC exam is not being conducted in person and applicants will not be able to perform physical examinations on standardized patients. Instead, applicants will be required to describe their approach to a physical examination in the stations. The NAC exam is typically offered in English and French, with the option to take the exam in French being limited to Montreal. It is held in multiple cities across Canada.

Eligibility and Application Process

The NAC exam, also known as the Objective Structured Clinical Examination (OSCE), is used to assess the knowledge, skills, and attitudes of international medical graduates (IMGs) and graduates of US osteopathic schools who are applying for postgraduate training programs in Canada. If you are an IMG or US DO school graduate and want to apply for a residency program in Canada, you will need to take the NAC exam and submit your results through the physiciansapply.ca portal when you apply to the residency programs through CaRMS.

When registering for the NAC exam on physiciansapply.ca, you will be asked to select 3 exam centers in order of preference. Although you can choose to only provide one or two locations, this will not increase your chances of being assigned to your top choice. In fact, providing 3 locations will increase your chances of being able to complete the NAC exam during your preferred time period.

The NAC exam is held twice a year, in March and September. If you fail your first attempt, you will not be eligible to retake the exam in the next time slot. For example, if you take the NAC in March of a certain year and fail, you will not be able to retake the exam until the following March. You are only allowed to take the NAC exam up to 3 times in total, regardless of the outcome. Once you have taken the NAC, your results are valid indefinitely, but only your most recent result is considered valid.

If you are an international medical graduate (IMG) applying for a residency training position in Canada, you will need to write the Licentiate of the Medical Council of Canada (LMCC) exam as part of your Canadian Resident Matching Service (CARMS) application. The LMCC serves as proof of your registration in the Canadian Medical Register and demonstrates your academic aptitude.

In addition to the LMCC, you may also need to write the National Assessment Collaboration (NAC) exam, which tests your practical competencies. While the NAC is not required to obtain the LMCC, it is required for your CARMS application. However, you do not need to take the NAC in the province where you plan to apply for residency, as the results are valid across Canada and will be accepted by all program directors.

It is important to keep in mind that passing the NAC and obtaining the LMCC does not guarantee that you will be offered a residency training position in Canada. Your residency application will also be evaluated based on other factors such as your CV, reference letters, personal statement, and performance in residency interviews.

What to Expect on the Exam Day

On the day of the National Assessment Collaboration (NAC) exam, you will need to register at the front desk. At this time, you will be asked to identify and have your belongings inspected. If you prefer, you can request that your items be inspected in a private setting.

It is important to note that there are certain items that are allowed in the secure exam area, such as a small, nut-free and fragrance-free snack in a Ziploc bag and a clear water bottle. You will also need to bring a white coat without any university logos, a printed entrance card, and a printed and completed copy of the candidate confidentiality agreements from the physiciansapply.ca website. A complete list of permitted items can be found on the official NAC website, including items such as lip balm, eyeglasses, and face masks. Some items may require special permission to bring into the secure area, such as medical devices that require smartphones to operate. These items are also listed on the website.

There are many items that are not allowed in the secure exam area, such as wallets, keys, coats, watches, bags, and stethoscopes. It is recommended to limit the number of belongings you bring with you as there is limited storage space on site. You will be required to wear a mask throughout the exam in all areas. You are allowed to bring your own mask, otherwise, a non-medical mask will be provided at the exam site.

It is important to arrive on time for the exam, as you may be denied entry if you are more than 15 minutes late for registration. Once the exam begins, your attempt will count towards your overall number of attempts to complete the NAC - you are allowed to take the exam up to three times. This means that even if you do not finish the exam, you will have used one of your attempts.

During the exam, you are not allowed to talk to other applicants who are also taking the exam. You are not allowed to bring watches or phones into the exam room. If examiners find a phone on you, your exam may be cancelled, and the results may be invalidated. There is also a possibility that you may be barred from retaking the exam and from the Medical Council of Canada (MCC) if you violate the rules.

When you arrive for the exam, you will be given a candidate identification number that you will need to read aloud at the start of each station. You will also be given an identification badge that indicates which station you will begin your exam at. You will be provided with a notebook to take notes during the exam, which you will need to turn in once you finish.

What to Expect in the OSCE Stations

The NAC OSCE exam consists of 10 stations, each 11 minutes long with 2-minute breaks in between to prepare for the next station. The September 2022 NAC exam will have 12 OSCE stations, one of which is a pilot station that will not be counted towards your final score and one of which is a wait station. Each station will have a description of the task to be completed, such as taking a history or conducting a physical exam. You will have 2 minutes to read the prompt and prepare before entering the station. A buzzer will signal when you can enter the station.

In the station, you will be joined by a physician examiner (PE) and a standardized patient (SP). You should focus all your attention on the standardized patient, who you will need to examine based on the prompt. You will have 11 minutes to complete each station. If you finish early, you will wait quietly until the station is finished. However, it is acceptable to re-engage with the SP if you think of something else to say or do. In some stations, you may be questioned by the examiner. This will be indicated in the station prompt. A buzzer will signal the time for the transition to examiner questioning while you are in the station. Once the physician examiner starts questioning you, you cannot re-engage with the patient even if there is time remaining.

The NAC OSCE exam is designed to evaluate your overall aptitude and readiness for medical residency in Canada. As such, the scenarios you may encounter at the stations will cover a wide range of medical practices. These scenarios come from:

  • Medicine
  • Surgery
  • Pediatrics
  • Obstetrics and Gynaecology
  • Psychiatry
  • Preventative medicine and public health

There are many tasks that may be asked in the prompt for you to complete during the station. You may be asked to complete more than one of the following:

  • Take a history
  • Describe a focused physical exam
  • Manage or resolve a patient problem
  • Counsel a patient or a family member
  • Answer oral questions
  • Summarise and present findings
  • Read or reference materials that relate to a patient including their chart, test results or medication lists
  • Interact with physicians or allied health members

How OSCE stations are scored

OSCE stations are evaluated by Physician Examiners who use a standard scoring instrument to assess a range of competencies based on the candidate's interactions with Standardized Participants. This instrument typically includes a checklist of tasks, an answer key for oral questions, and rating scales.

These competencies include:

  • History taking
  • Diagnosis
  • Management
  • Communication skills
  • Physical examination
  • Investigations
  • Data interpretation

Standardized guidelines are used for exam administration, the training of PEs and SPs, and the use of predetermined scoring instruments for the NAC Examination.

Effective strategies for studying

Form study groups:

  • A study group can be helpful, but it is important to identify the most important objectives for each group member to review. In addition, do not let the most competent members spend all their time helping others, as this can hinder their own performance and they need to be challenged. A useful exercise may be for each member to generate common patient presentations and present them to the group, where they can be critically discussed and challenged. This can help individuals think about other potential diagnoses, essential investigations, and physical examination assessments.
  • One way to challenge and engage members in a study group is to have each person generate common patient presentations that they understand well. They can then present these problems to the group and quiz others on how they would assess and manage the situation. It is important to be critical and challenge each other during these discussions. Group members should think about other potential diagnoses, how to differentiate between them, and the essential investigations needed. They should also consider what should be assessed during a physical examination and what other assessments may be necessary.

Create a study plan:

  • In order to effectively study and improve, it is important to identify the objectives that are most important to focus on. This may include common or critical patient presentations. In addition, being honest in assessing your own knowledge and abilities can help you target areas where you need to improve. Focusing on these key objectives and being self-aware can help you make the most of your study efforts.
  • To effectively diagnose and manage patients, it can be helpful to create differential diagnoses and identify key features that will help establish or confirm these diagnoses. Creating checklists and identifying key orders for investigations and management plans for each diagnosis can also be useful. If you find that you have a knowledge deficit in a particular area, it may be helpful to go back and review the basics in that subject.