Jennifer Smith* was hoping to see the words “general surgery” on her computer screen when she logged into the Canadian Residency Matching Service (CaRMS) website on March 1 of this year. She had applied to every general surgery program across the country. Instead, it said: “We regret to inform you that you have not matched to a program. Please click here for more information.” That was at noon. An hour later, Smith had to attend a meeting set up by her medical school for all the fourth-year students who hadn’t matched with a residency program. “I didn’t have time to cry or react,” she says. “The deadline for the second iteration match was in one week. I had to get myself together emotionally and figure out what to do next.”
What Smith is going through is the nightmare scenario of graduating medical students across Canada, and an increasingly real one as “match day” becomes more and more about not only where but also whether they will do their residency training. Medical school graduates need to complete 2–5 years of residency in a specialty—like family medicine, general surgery or neurology—to be able to practise medicine in Canada. Students apply for spots through a process administered by CaRMS that includes written applications, interviews and completing a ranked list of the programs they want to attend. The programs similarly rank student applicants, and an algorithm matches programs with students. There are two rounds of matching, with the majority of students matching in the first round and many of the remaining matching in the second.
However, in 2017, a record 68 out of 2,813 students did not match with any program after both rounds. This year’s number will not be known until April 11, when the second iteration is complete, but it’s expected to be even higher—anecdotal reports have it that as many as 222 students are unmatched after the first round. A report released this past January by the Association of Faculties of Medicine of Canada (AFMC) suggests that Canada is on pace to leave 82 students without a residency this year; by 2020, the number of unmatched is predicted to be 118. This is more than an entire class of students at most medical schools.
Why are more students going unmatched?
Myriad factors are in play here, not least the competing interests of the multiple stakeholders: provinces, which fund the residency positions and are concerned with the health needs of their populations (and thus want to fund more or less of certain types of specialties); residency programs, which want the best possible candidates and may only be able to offer a certain number of positions based on teaching capacity; and students, who are pursuing closely held career and life goals.
The overarching issue is pure numbers—more applicants every year versus a static or diminishing number of residency training positions. (Ontario cut 25 resident positions in 2016 and has been poised to cut 25 more, though this has been delayed.) There are two key dynamics contributing to this growing applicant pool. The first is that unmatched students from one year often re-enter the competition the following year. According to the AFMC’s calculations, if the first iteration was comprised only of current-year graduates of Canadian medical schools, the ratio between applicants and jobs would stay steady at roughly 1:1.056. But when you add in the unmatched graduates from prior years, “that ratio starts plummeting down,” says Genevieve Moineau, president and CEO of the AFMC, such that it is currently about 1:1.026, and is forecasted to dip to 1:0.99 by 2021. In other words, in 2021, for every applicant, there will be less than one training position available.
The second is that, as of 2007, most provinces have been allowing graduates of international programs to compete in the second iteration, greatly increasing the amount of competition. International graduates applying to the match are typically physicians who completed their training in other countries and may have already had significant careers before coming to Canada. They have also have completed a series of Canadian exams. In the past four years, international graduates have filled up to 50 percent of spots in the second iteration.
How does the system need to change?
There is consensus among groups like the AFMC, the Canadian Federation of Medical Students (CFMS) and the Ontario Medical Students Association (OMSA) that the provinces must add more residency positions, “to help us get back to a more reasonable ratio,” says Moineau. The AFMC has its eye on 1:1.1 as the target—meaning about 110 jobs for every hundred graduates—while the CFMS prefers 1:1.2, allowing even more room for students to match with programs they’re interested in. Moineau recognizes that this is a “big request” of governments which are “struggling to maintain the costs of their delivery of health care.”
Nevertheless, it’s the key thing that needs to change, say Andy Ng, who graduated from the University of Ottawa’s MD/Ph.D. program in 2017. In his fourth year of med school, Ng applied to neurology programs across the country and received interviews at almost all of them. “I had a pretty good CV, I did really well in my clinical rotations, and I got very good references,” he says. He believes that most schools were speaking to 40 to 50 students—for two or three positions. Still, he was shocked when he didn’t match. In the second round, Ng applied for family medicine which seemed to him a likely match—there were several positions in Ottawa and Calgary (there were more in Quebec, but to meet the needs of French-speaking communities it was expected that physicians in those programs would speak French, which Ng did not). In the end, only seven of the 14 U of O students who went unmatched in the first iteration found a spot in the second, and Ng was not one of them.
The second iteration is another focus of the AFMC’s recommendations. They are asking governments to revert back to a system in which only Canadian graduates are eligible to compete for the majority of spots left vacant after the first round. International medical graduates, by contrast, feel they deserve greater access to a medical career in Canada by being able to compete for the residual positions in the second round.
How do medical schools need to change?
After Ng went unmatched in the second iteration, he enrolled in the University of Ottawa’s fifth year of medical school, which allowed him to do 30 weeks of electives. “The first time around at U of O, we only got 10 weeks, pre-application (to CaRMS), and so most people spread themselves really thin, did two-week electives at many different places,” says Ng. In his fifth year, Ng spent up to six weeks in programs he was interested in, getting to know the residents and staff physicians, working to distinguish himself. In the process, he discovered a love for pediatric neurology—a different specialty than the one he’d applied for the previous year—and on March 1 of this year, he matched to that program at the University of Alberta.
The option to do a fifth year is an example of what the AFMC had in mind when recommending that faculties create “appropriate structures, policies and procedures” to help unmatched graduates find success. “Not only is it the medical schools’ responsibility to look after their students, it’s also their responsibility to support their graduates,” says Moineau.
There is work to do at the front end of medical school, as well. Primary care and generalist specialities are often where doctors are most needed, but some faculties appear to perpetuate the idea of family medicine as a “fallback” specialty, the thing you do if you can’t do anything else. “You get your lectures and education from specialists in big academic hospitals, and so you get a very skewed view of the appeal of primary care,” says Michael Herman, who graduated from McMaster in 2012. “They come in with their biases and their perspectives, the trope of the surgeon or the internist deriding the job the primary care doctor has done prior to the patient seeing the specialist.”
AFMC president and CEO Moineau says that medical schools are increasingly trying to prepare students for the fact that up to 50 percent of them will be matched into family medicine. “We’re trying to explain to students from the first week they come into medical school, ‘You have to realize that you are going to be supported now by society, by taxpayers, and what’s going to happen to you is in part going to be dictated by societal needs,” she says. Students must be flexible about their goals and apply more broadly to the match. Moineau says that the AFMC is trying to get a similar message to the residency programs, encouraging them to rank more students. “You may have your two top preferred candidates, but maybe there are 10 candidates who you say, yes, these people would be OK,” she says. “Well, then make sure that you put all 10 in the list of candidates you’re willing to accept.”
Smith, the student who is currently unmatched after this year’s first round, says she didn’t receive enough encouragement to adapt and make herself more competitive. “I heard the first-years received a scary email about backing up with family medicine after this year’s match results,” she says. “But going through, I was pretty set on not backing up. I didn’t get too much pushback. I met with our school career counsellor throughout and when I told them I’m only applying to general surgery, they told me based on my CV, they don’t seem too concerned.”
How can we better support unmatched graduates?
Unmatched students often experience a great deal of emotional distress and a sense of isolation and stigma. For many, connecting with peers going through the same thing is critical. Ng says that the meeting organized by U of O to help unmatched students prepare them for the second iteration was as—if not more—important for the opportunity to see that he wasn’t alone. “There were 13 other people in the same situation,” he says. “And [for] a lot of them, there were no red flags in their applications, they would make very good clinicians.” This year, in anticipation of Match Day, the CFMS set up a mentoring network, connecting previously unmatched students with those who have just learned they did not match. Ng is part of this network, and so is Jillian Follett, a graduate of Memorial who is now working as a family and emergency medicine doctor in Havre-Saint-Pierre, Quebec, and who went unmatched in 2014. “It’s great that the CFMS is doing this, but it would be cool if the universities already had it set up,” she says.
Herman, who didn’t match to anesthesiology in the first round of CaRMS, likens the experience to a “scarlet letter” in the medical community. “It’s like a shameful secret, ‘Oh, so and so didn’t match, did you hear?’” Herman, who now works in emergency medicine in St. John’s Newfoundland, recently posted his own story on Facebook, and several people have reached out to thank him for telling his story. Talking openly about not matching, he says, “normalizes the process and takes it away from this big, scary colossal, terminal failure.”
With only one surgical spot left in this year’s second round, Smith has accepted that she will likely not be a surgeon. At this point she just wants to match somewhere and move on. “We see all of our friends posting their CaRMS match results on Facebook,” she says. “We see pictures taken at the ‘Match Party’ on our news feed. It feels like everyone else is excited to move on, and we are held back, not knowing what the future holds. The worst part is getting asked the dreaded question, ‘What are you doing next year?’”
*details changed for reasons of privacy