Is every Canadian medical school graduate entitled to become a practicing physician?

If you’re reading beyond the title of this article, it is likely that you either believe this is already the case, or have a fairly strong opinion on the subject. In fact, I’ve come to learn that many Canadians, including medical school applicants and their families, believe that entry to medical school is the final major barrier to a career in medicine.

In the interest of ensuring a common starting point to this discussion, let’s clarify that a medical school degree does not entitle anyone to practice medicine in Canada. Graduates must also undertake and successfully complete a residency program. There are about 30 such programs available to graduates, all considered postgraduate programs within the same universities that house our medical schools, and all leading to qualification by either the Canadian College of Family Physicians or Royal College of Physicians and Surgeons.

Resident physicians, unlike medical students, are salaried during their training, which can last up to 7 years. The funding is provided by provincial governments, that therefore control the number and specialty distribution of postgraduate residency positions. In doing so, the number of medical school graduates is certainly known and considered, but the perceived societal need for physicians, both in terms of absolute numbers and specialty mix, is also a major determinant. The various ministries utilize complex but intrinsically imprecise methods to estimate those needs.

Each year, about 2900 students graduate from our 17 Canadian medical schools. There are a total of about 3300 postgraduate training positions available across Canada in all entry disciplines. In theory, there should be space available for all graduates. However, the specialty distribution of those positions does not match the career interests of the graduates. In fact, far from it. Some disciplines have many more applicants than available positions and are therefore highly competitive. Others that often fail to fill their positions. In addition, about 700 postgraduate positions are in exclusively French language environments and therefore not practically available to all graduates. Finally, each year about 2500 Canadian citizens or landed immigrants who graduated from schools outside Canada also apply for residency training positions. Although the number of positions for which they are eligible is restricted and controlled, they further reduce the availability of positions for Canadian medical school grads.

The net result of all this is that a steadily increasing number of Canadian med school grads are failing to find residency positions each year. This year, that number was 68, up from 46 in 2016 and 39 in 2015.

Depending on your particular perspective on this issue, those numbers may seem either insignificant or a major concern.

It is certainly true that the vast majority (over 97%) of Canadian graduates find residencies although not necessarily in specialties or locations of their choice. That is far more than occurs in virtually any other area of study or any other professional school, and may be seen as a reasonable concession in order to balance personal preferences against the societal need to have the right number of the right type of physicians in the right places, at least as assessed by those elected or appointed to protect the public interest. Medical education, after all, is not a right but a privilege, and a lucrative privilege at that. It is highly subsidized through the public purse, to the tune of an estimated half million dollars per physician in public funding. This is beyond the costs incurred by students themselves. It could also be rationally argued that an undergraduate medical education could serve as an excellent preparation for a variety of alternate careers, such as research, health system administration or medical technology.

Whatever your personal perspective, there are a number of consequences of this increasing phenomenon of “unmatched” graduates that must be considered.

  • The sizable societal investment in medical education noted above is clearly intended to result in a productive physician engaging the health concerns of citizens. Anything else is a misappropriation of resources.
  • The increasingly competitive environment for postgraduate positions is, understandably, becoming an increasing focus of attention to students. This influences how they engage all aspects of their curriculum and compromises what should be a time devoted only to learning and skill development. It also threatens the sense of collegiality and collaboration so important to a physician’s professional development and wellness.
  • Undergraduate medical education is designed and structured with the intention of producing practicing physicians. It is seen as a continuum of training that leads seamlessly to practice readiness. The academic and professional expectations of students are based on this assumption. If significant numbers of students do not progress in their training, that concept and educational approach will no longer be justified. Can or should such high standards be maintained if significant numbers of students are expected to consider alternative careers?
  • Students undertake considerable personal debt in supporting their medical education. The average debt in Canada is approaching $100,000, but ranges to over $250,000. This debt is supported largely by bank loans, provided on the assumption that the student will engage a career that will allow them to repay. Failure to engage postgraduate training can therefore trigger a need to repay a large loan with no means to do so. Failure to find residency training can therefore be a financial as well as personal disaster for these promising young people as they attempt to begin their careers.
  • If the ability to obtain loans become more constrained, the already acknowledged socioeconomic barriers to medical education and careers may increase, affecting already underrepresented populations.

 

Finally, there is a huge personal cost to bear for those who go unmatched. These young people, who entered the study of medicine with understandably high hopes and aspirations, are forced to face rather bitter disappointment and self-doubt, often for circumstances that neither they nor those who advise them fully understand. That reality has been evident to those of us involved in medical education for many years. Recently, this situation has taken on a public face, thanks to the willingness of the family of Robert Chu to share their personal loss.

 

The following is quoted from a letter Robert addressed to Ontario Health Minister Eric Hoskins April 18, 2016:

“Without a residency position, my degree…is effectively useless. My diligent studies of medical texts, careful practice of interview and examination skills with my patients and my student debt in excess of $100,000 on this pursuit have all been for naught.”

 

Robert took his own life in September of 2016, after two unsuccessful attempts to obtain a residency position.

 

We cannot presume Robert’s motives for his actions, nor can this tragedy be laid at the feet of any individual or institution. However, it would be equally wrong to dismiss Robert as an inevitable casualty of a flawed system. At the very least, he personalizes and therefore crystallizes this issue for us and we should not dismiss the opportunity he and his family provide to engage this issue.

And so, we return to the initial question posed in the title of this article. Are we willing to make a commitment to our students and ensure that they have the opportunity to complete the medical training they have begun, at considerable personal sacrifice? If so, then major structural changes in the postgraduate entry process will be required, involving either expansion or sequestering of entry positions for unmatched students. Such changes are far beyond what undergraduate medical programs can achieve on their own.

To not make such a commitment is a de facto acceptance of the status quo, since it is clear that the current circumstances will continue and the number of unmatched students will therefore increase. In that event, we should, at a minimum, be fully honest and transparent with our students and applicants, clarifying that admission to medical school provides no assurance of eventual entry to medical practice. We should also alter our curricular objectives and content to ensure students are prepared for alternative careers. With no clear linkage to residency and eventual practice, clinical and professional components of undergraduate education will eventually be de-emphasized and deferred to postgraduate years, likely prolonging overall training.

And so, it must be asked: When does professional training for medicine begin? At present, the presumption is that it begins at entry to an MD program. A growing number of unmatched students changes that paradigm and, with it, the pedagogical basis on which those programs are established. The consequences extend beyond the interests of the students themselves, although they would be reason enough.

 

Anthony J. Sanfilippo, MD, FRCP(C)

Associate Dean,

Undergraduate Medical Education

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Five things to do this summer: a Med Ed to-do list

This first year I worked in a post-secondary setting, I was somewhat bemused when students asked me how I was going to spend my summer – they were heading out on a three or four month “break” and assumed I was doing the same. Some had work plans, some travel, some both. Regardless, they would be away from campus and recharging their batteries, and, perhaps, expanding their perspectives in a variety of ways. I, however, would be at my desk.

Two decades and three universities later, I’m still working through much of the summer months as are many of my administration, staff, and faculty colleagues as we stagger vacations with other colleagues and other family members’ schedules.

For those of us at the School of Medicine (including our 2018 clerks!) who don’t have two or three months off this season but maybe a couple of weeks and the odd day here or there to make a long weekend – here’s my list of five things to do that are (loosely) related to medical education. (This list is best perused—and perhaps amended or augmented—while sitting on a patio with your favourite libation).

  1. Read something not related to your discipline

In the crush of academic terms, it’s easy to fall into the trap of reading for work, not for recreation. There’s always just one more journal article to be read, one more new text to review. One more thing to stay on top of. Vow to read at least one novel (or collection of short stories, or poetry) this summer. Regardless of genre, you’ll learn something of the human condition (which is at the heart of medicine and medical education) and it will refresh you, too. So, move it to the top of your To Be Read pile. Among my picks: a toss-up between finally reading at least one of the Harry Potter books, or Abraham Verghese’s Cutting for Stone. Maybe both. The Art of Adapting by Cassandra Dunn is also in the running.

  1. Binge watch a cooking show on the Food Network

Whether it’s TiVo’ed or Netflix, the ability to skip the ads is a godsend for a rainy Saturday’s binge-watching. Opt for something where you might pick up a recipe or tip or two, but pay attention to how the host explains what they’re doing. Is it conversational? Directive? Do you stay engaged? Or pick one of the competition shows (Chopped is my guilty pleasure) and check out how different judges give feedback. Some are brutal; some overly-kind without much substance. Some have thoughtful suggestions. Many adapt their critique delivery, based on the experience and competence levels of the chefs competing. How can this inform how you deliver feedback?

  1. Enlist some pals and build a sandcastle at the beach

Sandcastles are hands-on and best accomplished as a team effort. Building one requires both attention to details and a flexibility to accommodate the sand, water, and tide schedule. The plan is rarely ever 100% completed without modifications along the way. Plus, everybody gets dirty. And, at the end of the day, there’s nothing except pictures as the tide washes it away. So, a fresh slate the next day. And, we can take the lessons learned on to the next one.

  1. Hit the movie theatre to see a summer blockbuster

Enjoy the a/c and see something outrageous. Popcorn optional. Take note of if the story drags anywhere: did you get the urge to check your smart-phone (pre-movie admonishments aside). What made your attention wander? Was it an extraneous info-dump? An overly-long car chase? Just too much of something? A gap in knowledge? If you’re working on online modules for next year, take note of where the show lost you. Adapt this insight to material you create for your students.

  1. Watch some fireworks

Most of us know that fireworks were invented in China centuries ago. According to the “Fireworks University” website, this was an accident when a field kitchen cook happened to mix charcoal, sulphur and saltpeter. What a happy accident*.

There’s no great medical education insight to go with this watch fireworks suggestion: they’re just fun. And maybe that’s the insight right there.


 * (I feel obliged to stress the importance of  following all instructions for the at-home kind of fireworks and strongly urging you to show up for community fireworks shows instead. Avoid the unplanned side trip to the ER).

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Doctors, patients, ritual and showing up

Ritual is a big part of life; this is especially evident at universities at this time of year. I recently took part in the ritual of attending convocation at another university to watch my daughter receive her Bachelor of Health Sciences degree. In addition to the parental joy of seeing my daughter on stage for about six seconds of hooding and handshaking, I had the pleasure of hearing the convocation speaker, Dr. Abraham Verghese, a physician, author and professor at Stanford School of Medicine.

The importance of ritual, both in life and in particular in the doctor-patient relationship, is something Dr. Verghese is passionate about. He’s written about this, presented TED talks, and, late last month, incorporated this message into his convocation address at McMaster University.

Dr. Abraham Verghese (Screenshot from webcast)

Dr. Verghese noted that it’s possible to get your degree without attending the ceremony, but “rituals matter.” He added: “It says something about you that you believe in this ritual, that you showed up, because showing up for rituals that matter is perhaps the best advice I can give you.”

He acknowledged that he was speaking from “the vantage point of a window of practicing medicine” but hoped his message about ritual would resonate with everyone. He pointed out that the very ritual of convocation itself makes no sense in other contexts: “You’re dressed in a way that you otherwise never dress like. And I’m dressed as I rarely dress. With distinguished faculty on the stage, you marched in proceeded by a beadle carrying the mace, an instrument of battle that’s also a metaphor of power.”

“Our anthropology colleagues teach us that rituals are all about crossing a threshold,” he explained. “They represent a transformation, whether it’s a baptism, or a bar mitzvah, an inauguration, a funeral, a graduation.”

He challenged the graduates to consider what the rituals are in their lives, in their work, before sharing insight into his own understanding of ritual in his medical practice:

“If you think about the usual clinic visits, two strangers are often coming together, one person in the room will be wearing this white shamanistic outfit with tools in their pockets, and the other individual will be wearing a paper gown that no one knows how to tie or untie. The furniture in the room looks nothing like the furniture in your house or mine. The individual in the paper gown will then begin to tell the other one things that they would never tell their rabbi, or their preacher, and in my specialty of infectious disease, they will tell me things they would never tell their spouse. And then, incredibly, they will disrobe and allow touch, which in any other context in society would be assault, but the physician gets the privilege in the setting of this ritual.”

He further explained that this is not unique to any one culture. “I care for people from all kinds of ethnic groups, and I’m struck by how many different beliefs they have about illness, about disease, about treatment, but they all know about ritual,” he said. “And you put them in that room with all its setup and they know they’re about to embark in a ritual and if you do it poorly, if you just do a prod of their belly, and stick your stethoscope on the gown, they’re on to you, they can tell when you’re doing it well just as you can tell when you’re in the hands of a thoughtful barista, a good chef, a good hairdresser, a good mechanic.

“Rituals, done well, signify people who are doing their jobs well.”

Rituals can also be transformative, he said. “I learned this firsthand in the early years of the AIDS epidemic before we had any treatment,” he said, recalling a young man who he had followed for months at the clinic and who was now dying in the hospital.

“Each day I would come to his bedside and I’d visit him and I’d talk to his mother, and not knowing what else to do in this sacred hallowed space that surrounded him with his mother holding vigil, after a while, I would begin to examine him, albeit briefly. I would listen to his heart, I would percuss his lungs, feel his abdomen, feel his spleen, even though it was very unlikely I would discover anything that would change what we did,” he said.

“I engaged in this ritual out of habit, relieved that it gave me something to do, some purpose at the bedside.”

“One day, when I came by, his mother, that eternal figure there, told me that he’d not spoken or come to consciousness since the previous noon. It seemed certain that he was about to die, and in fact, he did pass away a few hours later,” Dr. Verghese continued. “But strangely, at that moment, as he heard us talking, as he heard my voice, we saw his hands begin to move. She was astonished, ‘cause she had not seen anything before. And I was astonished, and we’re wondering what is he gonna do? And we saw his skeletal fingers flutter up and then move to this wicker basket of a chest of his. And it took us a while to understand that he was fumbling with his pajama buttons. He was trying to unbutton his shirt, he was reflexively allowing me the privilege of examining him, giving me permission. I tell you, I did not decline the gift.”

“I percussed, I palpated, I listened to his heart, his lungs. I felt connected to the timeless message the physician conveys, the same message the horse and buggy doctor, riding out to towns on the western edge of Lake Ontario 150, 200 years ago, conveyed to his or her patients of that era, when there was so little to offer,” he said.

“The message is that beyond the data, beyond the evidence or lack of evidence, beyond the medicines that stop working, here I am and no matter what, I care, I will be there with you through thick and thin, I will not stop coming, I will show up.”

Dr. Verghese then spoke about emerging artificial intelligence and how it will change medicine.

“Here’s what’s not going to change, is the need for human beings to care for each other,” he said.

“We all need it in every walk of life, but especially in the care of the sick. I’m hoping that in my field, artificial intelligence will free us from some of the drudgery of medical record keeping and allow us to fulfill the Samaritan function of being a physician, to minister to those who suffer,” he added.

He exhorted the graduates to “embrace the rituals of your life, be conscious of them.”

“Be in charge and be cognizant of those human values and rituals that you want to preserve,” he added. “Remember that fluttering hand of the dying patient, I remember it every single day.”

Unlike machines, he said, “You can care, you can love, you can preserve the rituals that showcase these things. And you can show up. Always show up.”


You can watch Dr. Verghese’s full address here. It begins around 29:05.

 

 

 

 

 

 

 

 

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Sorry to interrupt but I just had this great idea: How learning about and adapting communication styles can help move group learning forward

When I last wrote to you in March, I asked if you were a constructive or destructive problem-solver in groups.  We do a lot of small group (and larger group) learning in Queen’s UGME and I hoped to give a great framework to help prevent groups from imploding before or while constructive work could be done.

We looked at identifying the types of problem-solving that might occur in a group and some strategies that could help prevent destructive problem-solving.  The ideas came from Team writing:  A guide to working in groups by Joanna Wolfe.  For this article, I wanted to share another set of ideas she has put forward in the same book, about Conversation Styles, and why they’re important to successful group functioning.

Why am I writing about challenges that small group learners can face?  In the research project that was the foundation for Wolfe’s book, she noted that nearly half the teams [she] observed experienced major breakdowns and that instructors responsible for teams were rarely aware of the problems students were facing, mainly because students almost never notified instructors of the problems and instructors had no independent information that could help them anticipate and head off trouble. (Preface, p. v)

I’d like to offer another of Wolfe’s frameworks to help anticipate and head off trouble and prevent implosion in constructive group work.

This framework concerns assumptions we make about communication styles including how we should talk to one another, what constitutes productive behavior and rude behavior.  Wolfe posits we need to understand others’ assumptions about “normal communication” behaviours and preferences in order to modify our own, and adapt to others’.

She provides a sampling of common communication norms (that are mostly extreme ends of a spectrum) and challenges us to self-assess, and also assess others in assumptions of appropriate and effective communication and teamwork.  While Wolfe discusses 3 types of communication styles (Discussion Styles, Presentation Styles and Problem-Solving Styles), I’ll focus on Discussion Style here.

We start with self-assessment and recognition.

In a self-assessment tool about discussion style,  Wolfe asks us to rate how well our behaviour is described in statements such as “When I get a good idea during a team meeting, I say it as soon as possible, even if I have to interrupt to do so.” Or “My teammates accuse me of not listening.” Or When a teammate expresses a new idea my first instinct is to point out the flaws” or “I think it is rude when my teammates never stop to ask me for my opinion,” or “If I need to express criticism, I am always careful to avoid hurting my teammates feelings.” (p. 84)

The outcome of the self-assessment is to place oneself on a spectrum of “norms”.  For example, the “Competitive Norm” is defined as “conversation [which] is a miniature battle over ideas. Speakers tend to be passionate in supporting their ideas and interruptions are frequent.”

 

The “Highly Considerate Norm” features “speakers who acknowledge and support one another’s contributions, and disagreements are often indirect.  Interruptions are rare and the conversation often pauses to allow new people to speak.” (p. 87)

There are pros and cons to each norm:  in the former while this style leads to fast-paced conversation and the often exciting challenge of publicly defending ideas in the face of competition, the most aggressive speaker rather than the best idea often wins out and speakers are more concerned with defending their own ideas than carefully listening to their teammates. In the latter, while there is concern for others, a polite tone and equitable conversations, the conversations may be perceived as slow-moving and even unimportant, and this norm sometimes privileges feelings and emotions over constructive criticism of ideas. (p. 87)

The idea is to recognize that there are values and assumptions to each style first and in this recognition understand the others in the group.  Then you have to learn to work with the others in the group.

So…if you identify yourself more with the “Competitive Norm”, what can you do to adopt a more considerate style? (Note, some of these strategies are from beyond Wolfe’s book.)

  1. Repeat back or restate ideas before disagreeing with them.
  2. Repair interruptions and other competitive behaviours with an apology (“Sorry, I didn’t mean to interrupt” or “I’m sorry—you were saying?”)
  3. Check in with the quieter speakers—often a job for a manager or chair of a group, but a person on the competitive norm spectrum could surprise everyone by doing this, asking, “Do you have any thoughts?”
  4. Pay attention to body language…pay attention to others.
  5. Listen.  (LISTEN!)  Write down good ideas.  Affirm non-verbally. 
  6. Write down questions or ideas you have, to save them for after the speaker has finished.
  7. Engage in uncritical brainstorming (all brainstorming is supposed to be non-judgemental but often people jump in with criticisms. Give a limited period for any ideas to be put forward with no judgement (say 10 minutes).  Members can build on another’s ideas and ask questions but do no fault finding.

And if you identify with the “Considerate Norm, how can you adjust to a competitive conversation?

  1. Prevent or forestall interruptions by saying, “I’m not finished yet,” or “One minute please.”
  2. Speak within the first 5 minutes of a meeting, so people don’t ignore you or think you’re peripheral.
  3. Find gentle ways to interrupt in a competitive conversation. Humour, such as waving a hand wildly, or timing interruptions so they don’t seem rude may help. Say (when someone pauses for breath) “May I contribute here?” “Is now a good time to hear from others?”
  4. Ask the chair to institute a round robin (everyone goes around the circle and contributes a set amount of time) or raising of hands or perhaps using the Indigenous strategy of a Talking Stick.
  5. I like these respectful but firm reminders to someone who is holding the floor too long from Sharing the Floor: Some Strategies for Effective Group Facilitation https://www.uua.org/re/adults/group-facilitation
  • “Excuse me, Francois, but I’m concerned about the time.”
  • “I’m going to stop you there, Laila, because I’m concerned that we are moving off our focus.”
  • “Francois, can you summarize your point in 25 words or less, because we need to move on.”
  • “Laila, is this an issue we can put on the Unfinished Business list? We can’t address it now.”

I would like to propose some steps from Wolfe’s discussion, to adapt our communication styles to the needs of a group and a group task:

  1. Self Assess: and be honest about your style
  2. Analyze: What’s positive about your style? How might your style be perceived negatively?
  3. Resolve: Decide what you can do to ameliorate some of the less constructive aspects of your style, while still retaining some of the positives.
  4. Enact: Practice in a group setting. Practice until it becomes habit.
  5. Seek feedback: Ask others:  Am I helping the group along?  Am I listening more? Am I contributing more?

Well! Speaking of communication styles, I apologize. I’ve talked for too long:  It’s your turn now 🙂

Do you think that this discussion about communication styles may be helpful to students? Perhaps helpful to your meetings (communication styles feature heavily in business literature about meetings)?
Let me know if you decide to use these strategies and steps.  I’d really like to see them in action and there are more wonderful ideas in Wolfe’s book!

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