The rotating internship was abolished in the early 1990s, mainly at the prompting of the College of Family Physicians of Canada to address shortages in Family Medicine. Prior to this, newly graduated medical students completed a one-year internship to obtain a general license to practice medicine and were then free to pursue further specialty training if they so desired. With the removal of the rotating internship, training requirements became two years for Family Medicine and 4-5 years for specialties.
After this change, concerns were raised about pressures on medical students to make premature career choices. As the CaRMS season descends upon the medical community for the 2013 residency match process, this discussion is particularly pertinent for fourth-year medical students (including myself) looking to make critical decisions regarding our future careers.
My first day of medical school was immediately marked with intense discussion surrounding which one of ‘The Big Three’ career paths I would choose. Was I destined to become a Surgeon? A Primary Care physician? Or perhaps I was interested in one of the many subspecialties of Internal Medicine? This was a topic that tirelessly dominated all conversation over the next 4 years. I asked my fellow classmates, ‘what is the single biggest source of stress and anxiety you have experienced during medical school thus far and what solution(s) would you propose for it?’ Over 70% of the people I asked said that concerns over the pressures related to early selection of residency was a source of constant distraction. One of my colleagues captured this particularly well:
I hate the idea that we need to commit to making the “right” connections and doing the “right” research before we even get close to a real patient. It undermines the whole idea of using clerkship (and especially our electives) to explore all the aspects of medicine and find what is right for us. I thought I was through all that the day I got into medical school, but it’s just getting worse. I am curious what would happen if they brought back the rotating internship year.
A study done at the University of Alberta examined students’ elective choices before and after the elimination of the rotating internship. 13% of the class of 1992 (prior to removal) and 52% of the class of 1994 (after removal) indicated that residency had a primary influence on their elective choices. 33% of the 1992 class had a narrow elective focus, compared with 49% in 1994. They concluded that residency concerns did have a significant influence on elective choices and that the choice of electives was narrower after the abolishment of rotating internships. This data is further supported by the fact that 59% of residents from the 2000-2006 CaRMS pool indicated that they had completed more than 50% of their electives in their first-choice discipline.
But would the return of a rotating internship really make a difference on premature career choices? The national colleges of family doctors and specialists have studied this issue, and their focus groups concluded:
No matter what type of selection takes place in the final year, the selection process will involve choosing electives, letters of references and interviews – delaying entry will not delay the decision-making process.
Beyond impacting elective choices, the rotating internship did more than just delay the decision of whether and in which field to specialize. It also exposed future specialists to the full spectrum of medicine. Some have argued that the elimination of general education has lead to a cultural and intellectual divide between family doctors and specialists, where specialists no longer ‘understand’ what family doctors do in their daily practice, and what kinds of health issues can be managed in the community setting. This leads, in their opinion, to a communication breakdown between specialties and the undermining of primary care.
In the 5 weeks I have spent in a family doctors office, I have learned enough to realize that there is an incredible breadth of knowledge required of them. They manage all spectrums of chronic disease. A post-graduate year spent in general practice would undoubtedly make me a more competent physician, but I believe at this point I have had adequate exposure to make an informed decision as to which field I wish to pursue for my career.
The direct effects on our health care system of the increasingly focused electives sought by medical students and the reduced exposure to generalist practice before becoming specialty-driven residents are certainly not clear at this point in time. I can say that I do not support the return of the rotating internship in its original form – this simply delays the inevitable. I prefer to imagine a system where residents in all training programs are exposed to a wide array of medicine and are given ample opportunity to switch to another program if they find themselves in one not suited to their interests or skills. This will require a percentage of current resident spots to be dedicated for switching and a culture within the system that accepts it. In an ideal world, we could all adopt the notion taken by past president of the Canadian Medical Association, Dr. Jeff Turnbull:
In providing the best health care for our patients and community, we must stop thinking of generalism and specialization as two opposing dichotomies, but consider them in a spectrum, with each uniquely contributing to the integrated delivery of health care. For optimal health care to be provided, a critical balance between generalism and specialization is needed. Neither can exist in isolation.
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Here it is six years since this article was published. Today (December 8, 2018) in the Halifax Chronicle Herald there is an article by Dr. Franklin Warsh entitled: Family medicine at death’s door in Nova Scotia. In response to this article, I’ve written an article of my own commenting on how the abolition of the rotating internship has led to this crisis in the shortage of Family Doctors in Canada. In searching the internet I found this well-written examination of the rotating internship. I am now retired (as of this week, December 2018) after having finished medical school in 1980, doing a one-year rotating internship and then working as a Family Doctor for two years. Subsequently, I went back to train as an Ophthalmologist, something I had not discovered until into the second half of my rotating internship. The one thing that a rotating internship provided was a constant supply of “transient” family doctors. The CCFP has eliminated this supply and this has ultimately led to the current shortage for reasons well described in this article and comments.
good analysis Kieran..
but I still think that one year of Internship is very useful , I have seen people (that I know very well) who took the one year Internship in other countries of the world, and they are more oriented and open-minded and have a wide thinking prospective in all aspects of medicine, and they can understand and appreciate all aspects and specialities of medicine.. I think that makes them better doctors.
I finished from medical school, and I’m very excited to do my one year Internship hopefully soon.
Perhap off topic but I do have a question. I live in PEI and we have an incredible shortage of doctors. Would it make sense tho I’m sure not your favorite idea, to have I terns do a rotation on the island? It would certainly be fulfilling the reason you wanted to be doctors. To take care of people in need of imedical attention. Probably a too simplistic answer to an serious problem but we are really hurting here
Thank you for your time
The return of the rotating internship will be meaningless unless general licensure is awarded with it.
The entire problem with the system now is that in order to practice general medicine, one has to “specialize” in family medicine. To do so is a career dead end, so students opt to specialize instead.
In the time before CaRMS, all graduating MDs were awarded a general license after completing a rotating internship. These doctors were then free to apply as many times as possible for specialty positions if they desired. Most did not want to re-train, and so the public’s access to primary care was better.
Hi Brooksbane,
Many physicians I have spoken with would strongly agree with your sentiments regarding the need for general licensure with an option to further pursue a specialization in Family medicine or other fields as they see fit.
I’ve heard many a complaint about ‘slave labor’ working conditions as a rotating intern, but with the recent advent of duty hours in Quebec, I’m sure this could be addressed by a similar model.
Yet while the public may have improved access to primary care per se, the issue of good continuity of care as a result of a shortage of Family docs might inevitably return as they were prior to the abolishment of the rotating internship. How would you propose to mitigate this possible issue?
Before I can give an answer to the question, I would like to know how continuity of care is at this present time. I suspect that it is no better, or potentially much worse, than it was previously.
The shortage of family physicians appears to be worse now than it was prior to the abolishment of the rotating internship. 50% of all graduating medical students went into primary care after their internship back then, compared to as low as 26% after the switch. The current numbers (around 40% if I recall) being celebrated by the CCFP fail to take into account the increases in medical school spots without a simultaneous proportional increase in all residency spots, which may not indicate that family medicine has increased in popularity but that more students need to use it as a back up.
Another thing that I find concerning is that there are no good published statistics on the number of family doctors who practice family medicine vs those that complete a family medicine residency but practice another component exclusively, such as ER, pain, derm, cosmetics, sports or what not. If the public benefits from full-scope primary care, we need to figure out whether our CCFP certified physicians are actually practicing it. I suspect a large number are not (look at how popular the R3 Emerg year is!)
Given the above two points, I wonder just how many true primary care physicians are actually out there.
The rotating internship, in my opinion, was a good thing. It allowed new physicians to have some autonomy and to make decisions like a doctor, not like a student. It offered broad practice experience in all major fields. It made the MD useful. And most importantly of all, it was not a career dead-end. One could choose to specialize years after the general internship, or to continue a well-established general practice. With this gone, a student is forced to choose between a specialty and the oft-loathed, oft-disrespected field of family medicine. Most choose the former. Those that choose the latter often practice a pseudospecialty, as I had mentioned above.
I will go as far as to say that the status quo serves as nothing more than a delusional attempt by the CFPC to maintain some sort of prestige among academic circles. It does nothing to serve patients, if the primary care numbers are any indication. Not only that, but rather than increase the ability of MDs to provide primary care by returning to the internship, the CFPC would prefer that medically unqualified ancillary practitioners like nurses, pharmacists and naturopaths provide primary care. How shameful! This organization deserves no respect. I’m not the only person that thinks this. Dr. Kennedy says just as much in the CMAJ in 2003.
hi Kieran. I am a journalist with the Medical Post. Some interesting ideas here. Would you (or any of your colleagues) be interested in talking to me?
Hi Kieran. Very interesting ideas here. I am a journalist with the Medical Postt. Would you (or any of your colleagues) be interested in talking to me?
Thank you Ken for your interest in the article and your comments surrounding these issues. I could not agree more with your sentiments regarding the use of medical school time to actually learn medicine! I wonder however if adding an extra year would change the CaRMS game or simply prolong it. As I mentioned in the piece, I believe that encouraging a culture in residency that allows for switching will take some of the pressure off of students to ensure they play the game ‘correctly’.
One could alternatively ask: is the purpose of residency to select and train doctors so that they are satisfied with their career choices; or is there a duty to meet the needs of society by training a certain number of specialties to serve in a variety of locations across the country? Can it be both?
The argument for reintroducing a rotating internship is less a concern about the decision making pressure, but the use of valuable medical school time to play the CaRMS game. People obsess about doing site visits, visiting the program director, and skipping out on their rotation to vie for something else. We should use medical school time to actually learn medicine. This is even more pertinent for those with three-year programs: It’s not getting easier to match into highly-competitive specialties, and they have less time to form a solid application to their chosen career.