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)
Undergraduate Medical Education