Tomorrow, final year medical students across the country (including myself) will login to the CaRMs website and learn our fates for the next 2-5 years. The ways in which residency positions are assigned were well discussed by healthydebate. The factors that contribute to medical student choice of discipline and location are widely varied and include everything from personal preferences in practice and lifestyle, training length, potential income, family obligations, and perceived job availability. A less commonly heard motivation among medical students is a sense of responsibility to select an underserviced specialty or practice location to be socially accountable. I would argue that this is largely because we are neither encouraged nor appropriately educated to do so.
As medical students, we are not adequately prepared to select our future careers according to our sense of social accountability. We receive almost no education with regards to physician resource planning in medical school. There has been an increasing awareness of the importance of primary care, and external support for students interested in family medicine is exceptional. This has translated to increasing numbers applying to the program, and anecdotally some of the most seemingly competitive programs among my peers in terms of interested applicants to positions are in family medicine. However, there is also a trend towards subspecialisation within family medicine (emergency medicine and anesthesia are most popular among my classmates) and many of my peers do not envision themselves in a primary care capacity despite their selection of family medicine residency. This is arguably due in large part to a lack of understanding of where the true needs lie.
In 2010, there were 242 certified geriatric physicians across Canada. This is in stark contrast to 2904 paediatricians. Despite this evident disparity, in the 2011 match there were 143 paediatric residency spots (100% of which were filled) and 26 geriatric fellowship spots (only 11 of which were filled). And medical students continue to seek training in well-serviced areas, with 6.9% of 2011 graduates applying for the paediatrics positions that represent only 5.1% of the national residency capacity. While the allocation of residency positions is complex and these numbers fail to distinguish between subspecialty versus community-based paediatricians, they nonetheless represent a clear failure of the system to build capacity in an area of apparent current and future need in favour of an area that is already relatively saturated with physicians.
Medical student perceptions regarding areas of need or job prospects are largely based on the experiences of our resident mentors who share their horror stories of being unable to find work following completion of their training or encouragement that a certain area offers significant employment opportunity. Considering that we are entering into a profession that emphasizes evidence based practice above all else, it is deplorable that our choice of career is informed by anecdotal evidence in the absence of any available thoughtful analysis of where we’re most needed. While we’re well informed that there is a significant shortage of rural family physicians nearing crisis, we’re given almost no information during medical school regarding the specifics of others shortages (psychiatrists, pathologists, and geriatricians) or the needs and job prospects in other areas of medicine.
It is not a reasonable expectation for faculties or even the Association of Faculties of Medicine of Canada (AFMC) to offer this education to medical students when they themselves suffer from a complete lack of reliable information. AFMC President Dr Nick Busing’s address at the 2011 Canadian Conference on Medical Education appropriately acknowledged that we are completely lacking any thoughtful health human resources planning model.
While provinces and medical schools attempt to allocate training positions based on societal needs, an isolated regional approach fails to acknowledge the fluidity and portability of the young physician population as well as the complex systemic issues influencing career patterns. For example, the incredible strain of practicing chronic care geriatrics in an acute care paradigm cannot be addressed without a comprehensive, national long term care and home care strategy. Appropriate health human resources planning will thus vitally require strong federal leadership. Investment in this kind of long term strategic planning will not only help Canada to make the best use of its medical graduates, but I believe it will also empower Canadian medical graduates to make socially responsible career decisions.
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Canada is unique in that it has no comprehensive health human resources planning capacity. In part, this reflects our decentralized system where education and health services delivery are provincially, rather than nationally, governed. And yet, as this article points out, graduating students compete in a national pool for residency training positions.
Although there are welcome initiatives being taken by the provincial physician regulatory agencies to standardize credentialing and certification procedures, there is no similar activity in the area of health human resource planning that would compare with Australia, for example.
The last national attempt to carry out physician human resource planning took place several years ago. It required significant government support. Unlike in the United States where the American Association of Medical Colleges actively engages in ongoing physician workforce planning, no similar activity goes on in Canada.
An additional difficulty is the de-linking between the production sector, I.e. medical schools, from the utilization sector, I.e. the health system. In the UK, for example, there is very close interaction between the postgraduate deaneries and the regional health authority. These entities, with the active participation of the Royal Societies, determine on an ongoing basis the regional physician human resource needs and assign training positions as a consequence.
Perhaps we need to think of something like this in this country. It would not negate the national matching exercise but it would make more explicit the number of training positions as a function of need. AFMC should lead the charge for this kind of approach and begin to encourage medical schools to align postgraduate training positions as a function of health system needs.
Thank you Ashley for the first hand perspective on a very important issue. Health care is first and foremost about people making careers out of serving the needs of other people – combining personal choice with societal needs. Changing the dynamics of the medical profession in this regard is clearly a major theme that not only affects the medical profession but also the relationship of the medical profession with the rest of society who depend on them as well as the many other health professional colleagues that work along side.
Great article!!