There is no longer any doubt that the number of unmatched Canadian medical graduates is on an upward trajectory that will certainly continue in the absence of significant interventions. We now know (https://afmc.ca/news/2018-04-17) that 115 students remain without residency positions after two attempts to “match” this year. That’s an increase from 68 from last year, 46 in 2016, and 39 in 2015, which means the number has almost tripled over those four years.

We also know of the tremendous individual burden of failing to engage a residency position which, while always very well understood by medical students and medical school faculty, has been made public through numerous articles and individual accounts:

https://atlantic.ctvnews.ca/medical-students-go-unmatched-despite-doctor-shortage-1.3884737

https://meds.queensu.ca/ugme-blog/archives/date/2017/06

https://www.thestar.com/news/canada/2017/06/17/tragic-case-of-robert-chu-shows-plight-of-canadian-medical-school-grads.html

https://www.universityaffairs.ca/features/feature-article/canadas-medical-residency-system-leaving-graduates-limbo/

Both the Association of Faculties of Medicine of Canada (AFMC) and Canadian Federation of Medical Students have developed position papers on this issue.

https://afmc.ca/sites/default/files/documents/en/Publications/AFMC_reportreducingunmatchedcdnmg_en.pdf

https://www.cfms.org/files/position-papers/agm_2017_support_unmatched.pdf

The upward trend is in keeping with the rather dire predictions of the AFMC position paper and has caused that organization, in a recent news release, to term the situation a “crisis”.

https://afmc.ca/news/2018-04-17

It has also spurred the Ontario Minister of Health, with urging from the provincial medical school Deans, to introduce a 23 million dollar program to provide supernumerary positions to, at least temporarily, provide relief.

https://news.ontario.ca/mohltc/en/2018/04/ontario-funding-additional-residency-positions-for-medical-graduates.html

This effort by our provincial government is very much welcome by both students and medical school faculty, and certainly provides very tangible evidence that the issue has gained attention and is being seriously engaged. However, it is clearly a temporizing measure, intended to stop the bleeding, not resolve the problem.

In medicine, we teach that problems can only be effectively engaged with a full understanding of their cause, or etiology. That process always starts with an examination of available facts, which are sometimes difficult to tease out from the subjective impression of a stressful experience.

So, what are the facts?

  • The number of residency positions available to medical school graduates is established by our provincial governments. They also very strongly influence the distribution of those positions between the 30 or so entry level residency programs. This is entirely appropriate to their responsibility to safeguard the public interest, both in terms of provision of health care and financial stewardship. No doubt they and their advisors make every effort to ensure that those positions match the needs of the communities they serve. Given the lag time inherent in the medical education process, this requires predicting future needs which, all would agree, is a difficult and inherently imprecise process.
  • Provincial governments have also made the decision to make some residency positions available to Canadian citizens and landed immigrants who have graduated from medical schools outside Canada (International Medical Graduates).
  • Students enter medical school with the clear expectation that any medical specialty is available to them but with little idea of which medical specialty they wish to engage, and with no obligation to undertake any particular specialty. Considerable effort and thought is expended by students during medical school to make those determinations. Those efforts are strongly supported by undergraduate programs through counseling and provision of career exploration opportunities.
  • Medical students make their own choices with respect to which programs they apply to, and how many programs they apply to. In doing so, they receive counseling from their schools, but are free to accept or reject any recommendations, and are well aware of which residency programs are more competitive.
  • Although the absolute number of residency positions is numerically similar to the number of Canadian graduates, the choices of students do not match the distribution of positions, resulting in a number of specialty programs being heavily over-subscribed and therefore highly competitive.

 

The phenomenon of the unmatched student is therefore the direct consequence of a mismatch between the specialty mix deemed to be in the public interest by our government, and the personal preferences of students.

It is also clear, given the current process and recent history, that the goal of matching every student to their specialty of choice is an impossibility. Intense competition for residency spots and increasing numbers of unmatched students are inevitable unless one or more of the operative realities noted above are changed. Fortunately, the Ministry of Health has, in the recent statement, committed to engage substantive change:

Ontario is collaborating with partners throughout the country to develop and implement a longer-term solution to this pan-Canadian challenge.”

Those charged with developing this “longer term solution” will, no doubt, be facing a considerable challenge, attempting to balance the government’s primary responsibility to public accountability, with the full freedom of students to choose any specialty. As they do, they will need to consider a few other facts concerning the educational experience of our students.

Medical school graduates are not yet able to engage practice. Medical education is a continuing process that transitions from university-based degree programs to residency positions that last a minimum of two additional years and which must be completed before a learner is even eligible to engage practice. While it is certainly possible for medical school graduates to take up alternate careers, that is clearly not their intention at outset, nor is it the societal expectation that establishes the number of medical school positions to match needs and heavily subsidizes medical education. The graduate who fails to achieve a residency is therefore denied the opportunity engage medical practice, and the training they have received to date is essentially wasted.

One could argue persuasively that the public interest, honestly and objectively interpreted, should always take precedence over individual preferences. However, most would also agree that every individual in a free society should at least have the opportunity to engage the profession for which they have undertaken training at considerable effort and personal sacrifice, and for which they have successfully demonstrated qualification.

Our students deserve the opportunity to engage a career in medicine and our society deserves a return on the investment they’ve made in their education. For those things to happen, our graduating students must have an opportunity to engage a residency program. Our ultimate solution to the unmatched student problem must, at a minimum, provide that opportunity.

 

Anthony J. Sanfilippo, MD, FRCP(C)

Associate Dean,

Undergraduate Medical Education