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.