When are Medical Students ready to decide?

Medical students begin their studies believing they have decided upon and achieved their career path, and can now devote their energies and attention to advancing that goal.  They soon learn that even greater and more complex decisions lay ahead.  The process of career selection has become a major cause of concern and stress for both medical students and curricular leaders at our Canadian medical schools.  Students must, by the end of medical school, select from among over 30 postgraduate training program options, which will further differentiate into over 70 approved medical specialty certifications.  Are students ready?  A recent, informal survey was carried out among the first and second year classes at our medical school.  Students were asked to state their agreement with one of three statements:

  1. I have a single, clear career interest.
  2. I have narrowed my focus to between 2 and 5 options
  3. I have no idea

Results:
results

So it would appear only a minority of our students have established a choice by these early years, although it’s unclear how durable these choices will prove to be.  It also seems that some further clarity emerges even by second year, but the majority of students remain uncertain.  Studies from the British medical educational system would suggest that about a quarter of doctors change their career choice after qualification (Goldacre MJ, Lambert TW, Medical Education 2000:34:700-707).  A review of Canadian graduates reports that 83% of graduates felt somewhat or very well prepared to make career decisions, but that leaves a full 17% who described themselves as “not at all sure” by graduation (Columbia B. Can Med Assoc J 1997;156:1248)

To illustrate how much the medical landscape has evolved, it might be useful to consider a “Tale of Three Classes”.

1870This photograph provided by Queen’s Archives illustrates one of our earliest graduating classes, circa 1870.  Students of that era received a common 3-4 years of instruction and clinical training, after which they were fully qualified practitioners.  Their scope of practice throughout their careers was virtually identical, determined only by the needs of the communities they served.

 

1981

 

 

 

 

Let’s move forward about a hundred years.  The second photo was taken at the 25th reunion of my class, Meds ‘81.  My classmates and I also undertook a common four year curriculum.  With one further year of training, in virtually any “internship”, we were all deemed fully qualified as “General Practitioners”.  About half the class remained in General Practice, eventually becoming qualified by the College of Family Physicians when that body and its qualifying examinations came into being.  The remainder went on to additional training in one of the limited number of specialty programs and certification examinations offered by the Royal College of Physicians and Surgeons.  Importantly, I doubt any of my contemporaries regretted their general training, and even those eventually engaging very specialized disciplines would say that their clinical proficiency and effectiveness was enhanced by that background.

2009Contrast all this to the graduates of Meds 2009.  About a quarter of these students undertook training in Family Medicine.  Many will, by now, have completed the minimum two year training program and will have begun practice, having passed qualifying examinations and achieved full certification through the College of Family Physicians.  The remainder are still in training, having undertaken further training through the CFP or entered a variety of Royal College programs, all with their own entry requirements, training program and qualification examinations.  Although their undergraduate experience would have differed in many ways from that of their predecessors, it was based on a structurally similar four year model, common to all students regardless of career direction.

The routes to practice are, in fact, becoming increasingly tortuous, complex and longer.  In order to better understand this, I’ve consulted with my colleagues in our postrgraduate education office.  Jordan Sinnett, PG Program Manager, provided me with the accompanying table that outlines the various paths to the current available postgraduate programs.   The reasoning by which some programs are direct entry from undergrad whereas others diverge after core training, and the length of time of various programs is all rather opaque, but appears to reside with the individual program committees.

It’s important, in considering all this change, to recognize that the major driver is the increase in medical knowledge, available technologies and vast expansion of valuable service the profession is able to provide to our patients.  Our society requires (and demands) physicians who have the highly specialized knowledge and training that’s required to diagnose and manage our ever-expanding array of conditions and provide technologically complex treatments.  This is obviously all good.  However, as training needs have increased, we have simply added more time and qualifications to those previously available rather than to consider new educational paradigms.  At this point, a few questions must be posed:

  • Is this a problem?  Stated another way, are there unintended consequences of this evolutionary change that should be addressed?
  • What, if anything, is being done?
  • How will all this affect our learners, and can they be expected to engage career selection in a different way?

Unintended Consequences

1.  Increasing focus of attention and stress for medical students.  The expansion of career options and requirement to choose from so many postgraduate training tracks is becoming an increasing focus (some would say obsession) of our students during medical school.  Observerships, interest groups, electives and even summer voluntary placements are all seen, and used, as opportunities to explore career options and advance one’s suitability for the increasingly competitive application process.  Although all of value, these pursuits compete with ever increasing educational demands expected of our students.

2.  Unhealthy competition among students.  Many postgraduate programs are over- subscribed relative to available training positions.  This results in a competitive environment at the very time medical schools are working hard to “undo” the pre-medical focus on superficial academic success and advance principles of patient-centred learning, collaboration and cooperation among colleagues.

3.  Subversion of medical education.  Medical school curricula are increasingly directed toward career exploration, to the extent that both core content and Electives (18 to 20 weeks at most schools) are essentially devoted to this purpose.  Career exploration is, in essence, subverting the educational priority.

4.  Increased time required to achieve practice readiness.  With the expansion of postgraduate programs and numerous emerging competency tracks, the duration of training is getting progressively longer.  Becoming a qualified interventional cardiologist, for example, requires 15 years from university entry (4 year undergraduate degree + 4 years of medical school + 3 years General Internal Medicine + 3 years Cardiology + at least 1 year Interventional fellowship).  Given that much of that time is spent in educational pursuits not directly relevant to the eventual practice requirements, the need for such a long training period is, at the very least, debatable, and given the increasing resource limitations of our health care system, will come under increasing scrutiny.

What’s happening that will affect all this?

The Future of Medical Education Postgraduate recommendations included the following:

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To implement this recommendation, the Association of Faculties of Medicine of Canada has established three committees with mandates to explore methods to refine processes within undergraduate programs, the transition from undergraduate to postgraduate education, and the transition to practice.  Those groups have been encouraged to think beyond current models.  Those revisions may involve more “streaming” or specialty-specific teaching during medical school, a more gradual transition from foundational to specialty-specific learning, and effective career counseling processes.

However (and this is a big “however”), any such change in the three or four-year common curriculum paradigm will necessarily require our students to make even earlier career choice decisions.  Is this a reasonable expectation?  The information I provided above would suggest they certainly are far from optimally prepared at this time.  So, what would be required to allow our students to make valid, durable career decisions earlier in their training?

The following would seem at least a reasonable place to start:

Clear and easily accessible information about the various career choices available to them.  Students need to understand the scope of specialty options and the essential differences, not only in clinical content, but also credible information about the “life” that goes with each.  They’re particularly interested in issues such as call expectations, mobility, and the availability of opportunities to integrate academic interests with their clinical obligations.

An understanding of their own preferences and aptitudes.  Students require direction and help in thoughtfully and honestly considering a number of personal issues relevant to career selection, such as:

  • Their willingness to engage patients with undifferentiated presentations
  • Their comfort with critically ill patients
  • Their comfort with continuing care versus issue-specific consultancy
  • Their comfort with surgery and procedural work
  • Their comfort with certain patient populations, such as children, the elderly, the terminally ill
  • Their comfort with various practice settings, such as hospital wards, emergency rooms, ICUs,  clinics, and offices
  • The degree of flexibility with respect to practice settings and mobility they wish to have

Although it can be very difficult for students, a full and candid consideration of issues such as these will allow them to reduce their reasonable options to a more manageable number.

Knowledge about availability of training and career opportunities.  Students have expressed very clearly their desire to know about long-term career availability.  Both shared experiences and recent studies (Frechette D et al,  http://www.para-ab.ca/upload/files/docs/employment/RoyalCollege_EmploymentSummary_2013.pdf) have suggested that many highly-qualified graduates of postgraduate programs have difficulty finding practice opportunities in certain specialties.  Students wish to have such information.  In this regard, they are allied with our provincial governments who seek to ensure our production of various medical specialists matches societal needs.  Unfortunately, accurate information is very hard to come by, particularly for students whose entry into the workforce is several years in the future.

An understanding of the application process.  Students need to understand the process by which they will apply and compete for postgraduate positions.  This requires clarity and transparency about both the matching and selection processes.  The former is carried out by the Canadian Residency Matching Service (CARMS), and is open, transparent and effectively provided.  The latter, which is in the hands of each specific postgraduate program, is considerably less transparent and subject to considerable rumour and “urban myth” among students.

Is there hope on the horizon?

All this requires a fresh, early and much more comprehensive approach to career exploration and counseling than medical schools have provided to date.   This week, those directing career counseling curricula and services at the six Ontario medical schools are assembling at the request of the Council of Ontario Faculty of Medicine Undergraduate committee to compare approaches, discuss challenges, and begin to develop more cooperative and effective approaches for our students.

The AFMC and ministry are jointly interested in providing more reliable definition of societal needs for all our specialties.  Such information will certainly be informative for our students.

The FMEC sub-committees mentioned above have, as a component of their collective mandate, consideration of improved student counseling and application processes.

These initiatives provide some optimism that students will be better prepared for their career decisions, and for the systematic changes likely to develop within our medical education programs in the coming years.  All these discussions and initiatives will be more effective if informed by those involved in (and effected by) the processes under discussion.  It’s in that spirit that this article is provided and your feedback is welcome. 

Many thanks to Jordan Sinett (Postgraduate Program Manager), Sarah Wickett (Health Informatics Librarian, Bracken Library), Jonathan Cluett (Meds 17 Class President), Sean Henderson (Meds 16 Class President), Jennifer Siu (Meds 16) and, as always, Lynel Jackson, for their assistance in the compilation of information for this article.