As Director of Specialty Education at the Royal College of Physicians and Surgeons of Canada, I was interested to read Kieran Quinn’s recent blog post entitled “Should we Embrace a Return of the Rotating Internship?” Mr. Quinn’s thoughtful post echoes many of the sentiments that the Royal College has recently embodied in its initiatives and policy decisions. Improving decision-making and promoting generalism are vital in medical education. However, returning to the rotating internship may not be the best way to accomplish these goals.
As Kieran Quinn noted, the rotating internship was abolished in the early 1990s. I myself went through residency soon after this change. Some stakeholders have since pleaded for its return, citing passionate opinions as to its benefits, in terms of providing broader exposure to clinical disciplines and a delay in career decision-making. That is why the Core Competency Project (CCP) was undertaken in 2006, in partnership between the Royal College and the College of Family Physicians of Canada, to examine this issue among other key questions facing residency education in Canada. This was a multi-year, mixed methods research study, which Kieran cited in his article.
The data from the CCP suggests that the rotating internship is not the solution to mitigating challenges regarding career decision-making. Furthermore, the promotion of generalism in residency education is not necessarily aided by reintroducing the rotating internship. The available research indicates that there are other factors, such as the presence of role models, which influence whether or not a physician in training adopts a generalist practice. The final recommendations of the CCP (p.44) were made in this spirit.
As noted by Kieran, the findings of the CCP demonstrated that a return to the rotating internship was perhaps not necessary for the promotion of effective career decision-making, as the majority of medical students, residents and ultimately, practicing physicians were ultimately satisfied with their chosen career discipline. In addition, many of the stakeholders consulted expressed concerns that any move to delay the timing of career decision-making, would not alleviate the stress that is inevitably associated with the decision-making process (CCP pg. 20-21).
The other commonly cited argument for rotating internships is the breadth of exposure it provided. It is a commonly held value that residents benefit from broad educational exposure and that generalism is a central tenant across medical training in Canada. However, the findings of the CCP suggest that other innovations can be leveraged across the medical education system to better support important career choices and to promote exposure to generalist disciplines and broad-based training.
The late Dr. Robert Maudsley, perennially ahead of his time, spoke eloquently about the importance of foundational training in the promotion of generalism over 15 years ago. Recognizing this, and after significant consultation, the Royal College recently enhanced its criteria for discipline recognition, and created a “fundamentals” category of discipline recognition. This category now provides an option for families of disciplines wishing to pursue a common core program for the early years, i.e. first one to three years, of training in a primary specialty, to promote broad-based training, exposure for appropriate career decision-making and flexibility in medical education. This option is available for all families of disciplines recognized by the Royal College.
We must also explore other innovations that could foster generalism in training. For example, a national consensus conference on the future of generalism in medicine was held this spring, part of a broader attempt to re-ignite a national level debate on the future of generalism in medicine and to discuss strategies to support the development of generalism. A key next step that emerged was the need for all stakeholders in medical education to collaborate and design new educational models that promote the value of generalism for trainees.
Many other innovative ideas and approaches also exist. Embracing these innovations will contribute to health workforce planning that embodies, as the Future of Medical Education in Canada Postgraduate (FMEC-PG) articulated, “the right mix, distribution, and number of physicians to meet societal needs”. Rather than returning to rotating internships, other innovations are needed to enhance our medical education system.
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I think in all of this mess we are forgetting the patients we serve.
The part that nobody seems to take into account in favor of the return of the rotating internship is that
1. the MD degree is a virtually worthless piece of paper without a residency
2. students have one opportunity in their lifetimes to choose a residency, be it lowly family medicine or an exalted other specialty
3. most students choose the latter
4. therefore, primary care has a big gap in it where patients just aren’t getting the care they need
5. nurses, naturopaths, homeopaths and pharmacists want to provide this care, and we appear to be letting them do it since primary care is beneath most of us.
This “shortage” or “maldistribution” was nowhere near as prevalent in the days of the rotating internship. Every medical school graduate came out with the skills to provide primary care, and far more of them stayed with it than not. Now, even with those who go into family, you’d be hard pressed to find any that provides full-scope primary care. Where there’s a need, someone will fill it, and right now that someone is a mid-level provider who in my opinion should not be making independent medical decisions.
As a self-regulating profession, we are given status, prestige and financial rewards because the public trusts us to provide them with what they need. We’ve failed to do so because our egos transcend our ethics. When Dr. Nurse is serving our patients, the public will no longer trust us, and we will lose the bond that we’ve tried to maintain with them for years.
Here’s what needs to happen:
1. All medical schools go to three year programs. Mac and Calgary do it this way and their graduates are no less prepared for medicine than the four year programs’ graduates.
2. All graduating medical students do a “family medicine” residency of two years duration. I’d much rather select a one year rotating internship like in years prior, but the CFPC are a whiny Napoleonic bunch so this is a compromise. All medical students would be able to provide primary care in 5 years. That’s a 100% primary care practitioner training rate.
3. Specialist positions need to be reduced in number to match demand and availability of resources like ORs etc. There are too many ortho spots and nowhere near enough derm spots, for instance.
4. CaRMS is open to any physician with an MD from an LCME accredited institution. The applications are not broken up into the first round, with all spots available, and the second, which is generally filled with garbage nobody wants. That way, should someone want to specialize but not be picked one year, they can provide primary care until the next. I bet many would be happy to just stick with primary care at that point rather than take the huge paycut and massive undertaking that is a five year residency.
Unless the MD degree awards someone the ability to provide general medical care, the concept of generalism is meaningless.
You guys better get back to the drawing board and come up with a tangible solution, because right now things are nowhere near optimal.