Each year thousands of medical students across Canada apply for, and are matched to, residency positions in a variety of medical specialties.
The allocation of residency training positions among the various specialties is largely decided by academic doctors involved with medical education.
Some experts believe that health system decision makers should exert greater influence over how residency positions are divided among specialties.
Bourne Auguste is in his final year of medical school at McMaster University. On March 6th, he will log in to the Canadian Residency Matching Service (CaRMS) website and find out what residency training program he has been matched to. Auguste hopes to pursue a career in internal medicine, and says that he made his decision based on his “affinity for internal medicine and the opportunity for jobs in the long run.” CaRMS, which is overseen by a board that includes medical students, residents and university representatives, performs a crucial role as matchmaker. But it has no say regarding how many positions are offered in each specialty.
Health care needs and the supply of doctors
A recent Globe and Mail article noted that growing numbers of orthopaedic and cardiac surgery residents cannot find jobs in their field after they finish their training. At the same time, jobs in other fields such as geriatrics, psychiatry and pathology go unfilled.
As population needs change, so too does the demand for different types of doctors. New treatments play a role too. For example, medications and minimally invasive procedures have resulted in coronary artery bypass surgery being recommended far less often to patients than previously. The popularity of different medical specialties among medical students has also changed over time, in part due to financial considerations, in part due to on call requirements, and also for reasons that are less well understood. For example, despite a plethora of available jobs, very good remuneration and limited on call requirements, only 11 medical students in the entire country ranked anatomic pathology as their first-choice specialty last year.
The relationship between ministries of health and universities
Provincial ministries of health fund provide funds to universities and hospitals for a specified number of residents each year. Although the Ministry of Health and Long-Term Care decides on the overall number of training positions, it plays a much smaller role in determining how these positions are allocated among the various specialties.
In Ontario, representatives from the ministry work with program directors and medical schools deans on a subcommittee of the Council of Faculties of Medicine of Ontario. This subcommittee considers forecasting data using a simulation model developed by the Ministry and the Ontario Medical Association. Residency training program directors also monitor factors such as job prospects and training capacity. In recent years, the ministry has required residency programs to increase the number of family medicine positions, and also placed special emphasis on a few specialties such as critical care and geriatrics. But decisions regarding the allocation of spots between most specialties are generally left up to the universities. From the perspective of residency program directors, this makes sense, in part because teaching hospitals depend on the highly skilled and relatively inexpensive labour provided by residents.
Should government play a larger role?
However, some experts believe that ministries of health need to play a greater role in determining the number of training positions available in each specialty. Peter Walker, former Dean of the University of Ottawa Faculty of Medicine, points to the United Kingdom as an example. In the UK, work force directors in each of the health regions play a large role in deciding training positions in their region. Similarly, in Quebec, each health region develops a human resources plan that sets out targets for the types of doctors and specialists needed in each region. Walker argues that “Ontario could benefit from a regional planning approach” to residency positions rather than an approach led mostly by universities.
Sal Spadafora, Vice-Dean, Postgraduate Medical Education at the University of Toronto, says “we could benefit from joint health human resources planning at all levels and right now it appears as if each jurisdiction is acting independently.” Walker makes a similar point, noting that "medical schools that do human resources development have to respond to a societal need and I don’t think that right now there is enough of a feedback loop into the educational system from governments who are responsible for responding to population health needs.”
All of this may seem a little abstract to a medical student like Auguste. Fortunately for Auguste, the demand among medical students for his chosen specialty of internal medicine is not larger than the supply of positions. As a result, the vast majority of medical students who ranked internal medicine first ended up in an internal medicine training program.
In contrast, despite the reported shortage of pathologists in many parts of Canada, almost one-third the available positions remained open after the main match, and most of these remained unfilled even after the second round.
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Ritika says:
“family medicine is something you do for the long haul, not just when you feel like it.”
It is this kind of delusional pride that is responsible for the primary care maldistribution in Canada.
There is no evidence to suggest that a 2 year family medicine residency produces better primary care physicians than the general one-year internship. See that: no evidence.
Limiting primary care physician output to maintain your field’s sense of pride and “specialtyness” is deplorable and does not help your case.
Einstein was quoted as saying that insanity is doing the same thing repeatedly but expecting different results each time. The “academic” family docs and their ilk fit this description quite nicely.
Thank you, Joe, for your somewhat abrasive remarks. I agree with you that back when being a family doc meant having gone through the rotating internship of one year and weighing your options of going back in for specialization vs going into a job and making money right away, family medicine probably did look appealing. My concern is less whether it ‘takes’ one year or two to become a family doc (or three as they do it in the US) and more whether we will be inviting in a whole crop of people who really have no interest in pursuing family medicine as a career. As well, you mention that many chose to get a few years of real-world experience before specializing which is also concerning since family medicine is something you do for the long haul, not just when you feel like it. We make a commitment to our patients and this continuity of care is invaluable. Clerkship is the time to figure out whether or not you want to pursue a career in a certain field. Of course one can always retrain and should have the opportunity to do so if they feel unhappy or unfulfilled in their field, but to set up a system where new grads do family medicine ‘for a couple of years’ until they pursue specialization is not a good plan.
I also find your portrayal of family medicine as a “lower-paid, less-respected, lower-impact” field highly concerning. For one, it is laughable to consider family medicine a low-impact field since family docs are the first point of contact, the gatekeepers to referral, and the implementors of preventive medicine and public health measures. It is absolutely lower-paid and among people such as yourself, less-respected – but I don’t see these as reasons to throw up our hands, but rather things we should work to change. Much has actually been done to raise the reimbursement rates of family docs, and while I don’t necessarily feel the absolute value needs to change, I do think the relative value in comparison to many ridiculously paid specialties does need to change.
What I wrote about promoting family medicine was written exactly to combat the kind of unnecessary smearing that family medicine has to endure on a regular basis which you have here propagated. Let’s not forget, there’s a reason we want 50% of our doctors in Canada to be family doctors.
Regarding anatomical pathology, the field doesn’t attract many applicants because of a plethora of reasons:
1. There is zero exposure to it in medical school
2. The field is responsible for autopsies, however infrequent. This is a turn off for most people.
3. The stigma that pathologists are poor communicators and weirdos that can’t deal with patients still exists.
4. The recent scandals regarding flawed pathology results makes the field look like its full of inept people.
5. Most of the available jobs are in Quebec, which is known to be a bureaucratic nightmare and requires its physicians to be fluent in French. In the rest of the country jobs are scarce.
6. The field enjoys very little autonomy, with much of the control of the practice ceded to hospital adminstrators.
7. The remuneration varies heavily between provinces.
With all due respect to Ritika, promoting more “family medicine” exposure in medical school won’t do jack to actually attract more people towards it.
The main problem is that prior to 1993, all medical graduates were considered “general practitioners” after a year of common rotating internship duties. Everyone graduated on the same page, and most opted to be family doctors for a while, obtaining real-world experience before deciding whether to specialize or not. Most did not specialize because going back for residency involved taking a 75% pay cut and working hard hours for another four or five years.
When 1993 came, doctors could no longer practice generally out of the gate because the CCFP(Canadian College of Family Practitioners) was feeling inadequate and wanted more respect, so they made it mandatory for people to do a “specialty residency” in “family medicine”, if they wanted to do the generalist practice as was common in the past. But if doctors did that they could never re-train in something else. So students, being astute, go for specialty residencies straight out of the gate, rather than take their chances on the lower-paid, less-respected, lower-impact field of family medicine.
If you want more family docs, the barriers for entry have to be lowered. Right now they are far too high. The CCFP needs to back off and return to a general internship model. Family medicine is not a specialty and the faster that is realized, the better things will be.
Or they can just do what they are doing now and take the scraps that didn’t match to residency positions and IMGs.
This is a very topical issue. One aspect that was perhaps less well covered in your piece was the gap between societal need and hospital resources. For example in orthopedic and general surgery, there are long waiting lists for joint replacements, cancer surgery, and sometimes emergency surgical coverage can be spotty. However there are “no, or few jobs”. This is in part related to the fact that peri-operative budgets have contracted year over year (poor fiscal climate); and it is requires an allocation of resources on behalf of the Hospital to hire a new surgeon.
This sad fact is limiting the number of new surgeons in these two surgical specialties specifically, while patients wait longer and longer to have surgery.
Thank you for this important discourse.
Thanks for this great piece! This is a hugely overlooked issue and in fact, I think most Canadians would assume that the government already does play a role in residency position determination. Not only should the government be involved in properly surveilling patient care needs to determine where more/less specialists are needed, but it needs to be supporting medical schools in promoting certain fields.
The major one that I feel needs a lot of promotion is family medicine, not only because it is a major unfulfilled need in society but also because of the character assassination family medicine often goes through during medical training. Medical students are usually trained by subspecialists, and rotate through different areas of medicine for 4-6 week blocks. This setup is not conducive to appreciating the beauty of family medicine – slow building of patient rapport, continuity of care, watching disease progression over time – these aspects are not appreciated in a short period of time. There is also a bias against family medicine often propagated by attendings in other specialties. I recall the response when declaring my interest in family medicine was one suggesting that I had no motivation in life to try for something ‘better’. Often during case presentations, snarky mentions are made of things the family doctor ‘missed’ of course stated in hindsight once the presentation was so obvious that the patient knew to go into the hospital. We need to put pressure on our learning environments to do away with such unhelpful negative stereotyping and instead expose students to the beauty of family medicine early on in their careers. A strong and well-functioning primary care system is the backbone of medical care and without family doctors to fulfill this role appropriately, we cannot provide the care our patients need.