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Unmatched Canadian Medical Graduates

Unmatched Canadian Medical Graduates

Guest blog by Andrew Dawson, a 4th-year medical student at Queen’s and the current Chair of the Ontario Medical Students Association

Medical students are selfish.

This shouldn’t shock or offend you. The reason I make this sweeping generalization is not because I believe that it is a revelatory statement, but rather that thinking in this way allows us to reframe an important and timely issue in the world of medical education - that is, the unmatched Canadian Medical Graduate (CMG). Selfishness happens to all of us at times, but it may increasingly be gaining momentum in medical students out of perceived necessity.

Starting clerkship, medical students are just starting to flex our diagnostic muscle. Sure, we’ve learned how to conduct a history and complete a physical on basic patients with common presentations. But when faced with a clinical picture that doesn’t fit into tidy algorithms, we are confronted by just how little we truly know. And that self-realization is a frightening and powerful thing. After all, once we recognize that we are mostly incompetent, what is there to prevent other people from noticing our woeful inadequacies too?

To combat this, medical students steer towards selfishness. We become so concerned with figuring out pathology and disease, so hell-bent on impressing preceptors with our finely tuned investigative toolkit, and so stressed about missing something that might impact an assessment we receive, that we disconnect from the individual we are treating. We rush past patient anecdotes and jokes and the staples of regular conversation. No longer is this a person with a life, a family, and a personal history; they are a riddle that needs prompt solving.

But let us qualify this vested self-interest and flesh out why this occurs. Med students are often taught to believe in meritocracy. If we successfully tick off all the necessary boxes - the grades, the extracurriculars, the award-winning research - most of us have been lead to believe we’ll find a career waiting at the finish line. In the past, this may have been accurate. However, that reality is becoming less and less common, as recent health and human resource planning decisions have left more and more medical students without residency positions. This year there were over one hundred and twenty Canadian medical graduates without a residency position after the second iteration of the CaRMS match. The future of their clinical careers in medicine now in question, they will scramble to arrange supplementary electives, enroll in Masters programs, and bulk up their applications to run through the CaRMS gauntlet next year. But going unmatched even once acts a scarlet letter and many of those individuals will never match. Sure, there are non-clinical careers available, but that remains a bitter pill for many students to swallow. Some will leave the profession entirely. And that leaves us with highly trained and motivated individuals with limited career options in a brutally stigmatizing and unforgiving medical community. Let’s not forget the staggering six-figure debt load that seems impossible to pay back without a physician’s salary. It is no wonder medical students are running scared. As the stakes grow higher and the perceived margin for error grows slimmer, becoming more self-focused and evaluation-oriented is necessary. It seems like the only way to keep our heads above water.

So the question needs to be asked: has the hyper-competitive and cut-throat environment (whether perceived or real) resulting from fewer residency spots changed how medical students interact with their patients? I recently completed a family medicine rotation in Brighton, Ontario. The physicians I worked with made it clear from the beginning that they wanted medical students to take time to talk to the patients; that focusing on efficiency doesn’t necessarily make for the most effective appointments. I was permitted to take extra time without fear of reprisal from my preceptors for working too slowly. And it has been completely rejuvenating to listen to people tell their stories. The richness and quality of these people’s histories – not just medical histories for once – helped me to re-center and refocus. It reminded me that I chose medicine because of the people I would be afforded the opportunity to care for. Chronic stress can chip away at even the most empathetic and optimistic of people, however, taking the time to talk to patients about their personal circumstances, and the contexts surrounding their illnesses helped me reclaim my professional values. Moving back into hospital medicine following the conclusion of my community rotation I worried about falling back into old habits and anxious thought-processes. I’m not alone among my peers in this line of thinking. I can’t help but wonder if the hyper-competitive environment medical trainees are entrenched in has caused an erosion of the ‘soft skills’ in medicine that often resonate the most with our patients.

Moving forward, how do we shift this cultural paradigm? When it comes to residency spots, we need to either decrease the inflows, or increase the outflows. It will require a multi-faceted approach from all relevant parties. It will require more appropriate matching strategies. It will require oversight from the Council of Ontario Faculties of Medicine (COFM) and the Association of Faculties of Medicine of Canada (AFMC), as well as input from the provincial ministries responsible for residency position allocation and funding. It will certainly require buy-in from med students themselves, and representative associations like the Ontario Medical Students Association (OMSA) and the Canadian Federation of Medical Students (CMFS) have been working hard to keep student interests heard. Earlier this year, the Provincial government took steps to alleviate some of unmatched backlog by allocating one-time funding for fifty-three new residency positions for unmatched graduates from Ontario. While I commend the government for this initiative, it is ultimately a one-time measure; a system-level overhaul needs to occur if we are to effectively address this expanding problem. But everything is in flux and shrouded in uncertainty, and none of the key players really seems to have a pulse on what the next steps should be. Though no one is to blame, downplaying and deferring the significance of unmatched CMGs does not serve anyone. This issue demands prompt attention.

Until something changes, fears of not matching will continue to alter how medical students interact with their patients. Until something changes, medical students will continue to be selfish.

 

 

Leda Raptis

Wed, 08/01/2018 - 18:36

You forgot to mention that there IS a place in the economy for more doctors. Think of wait times, that end up costing more, not less, if eg cancer surgery is delayed as the cancer spreads...

Leda Raptis

Nicole Hawkins

Fri, 08/03/2018 - 10:32

Excellent article. Even though I graduated in 2009, I felt immense pressure trying to match to a competitive specialty (as did many of my colleagues), and I admit that it did detract from my enjoyment and commitment to other rotations during Clerkship. I can only imagine how stressed students are these days when "going unmatched" is a more and more common occurrence. I would be interested in the CFMS / OMSA opinion on bringing back a rotating internship. Do you think that this would shift some of those pressures down the line a bit? Additionally, it might give "the system" some time to catch up with the outflows portion of the equation.

Nicole Hawkins

Dr. Garry L Willard Meds'63

Fri, 08/03/2018 - 15:34

Three comments:
Firstly, you can never spend enough time with a patient but if you try , Wm Osler's dictum comes into play. Namely, "If you spend enough time with a patient, the patient will give you the diagnosis."

Secondly, the time to revive the junior rotating internship has surely arrived. Provided appropriate funding by whatever level of government is in place there are literally hundreds of positions available in University Centres and Affiliated Hospitals. No rush to decide on your specialty in medical school. Reduces stress (and selfishness). Allows for exposure to services one might have missed in medical school elective rotations. Besides, a better exposure to multiple disciplines makes for a wider knowledge base and more extensive skill sets. One needs to be a good well rounded doctor before one can seriously consider one's aptitude for a specific specialty. That extra time in a rotating internship is well spent.
Thirdly, prior to a commitment to years of specialty training there should also be consideration of spending a year or two in an underserviced area. This will soon highlight any deficiencies in education or training and will give stronger focus when specialty training begins.
Like many other medical students of my era, I was accepted into Queen's straight out of high school at age 18. This fast track then allowed one to go directly into the Faculty of Medicine and get immediately outfitted in the vaunted blue leather jacket .There was a two year Premeds course then four in Medicine. No requirement for a previous University degree. No computerized placement for junior rotating internships then. No you simply made arrangements for interviews at prospective hospitals and hoped you got your preferred choice ... took a bit of footwork and enthusiasm though.
Prior to spending a year at remote Norway House Manitoba ,as a general practitioner, responsible for overall care including obstetrics and emergency surgery , a crash course in anaesthesia and extra time in OB were de riguer. Returning and starting a 5 year general specialty surgical rotation was facilitated by the Course Director's willingness to be flexible. After a year in the North treating primarily a Cree population I had become aware that to be a good surgeon one needed a stronger background of internal medicine. A request for a 6 month rotation in Cardiology and Geriatrics was met with confused looks. "Dr. Willard, Do you want to be an Internist or a Surgeon?" "Well sir, having been through a rotating internship and the practical exposure to practice in the North, I believe that I now know what I don't know." The request was granted for the first time in the history of the Course. That proved to be another benefit of extended training.
With best wishes to all those still seeking residency positions. Persevere!
Garry L. Willard MD FRCSC FRCSEdin FACS FICS

Dr. Garry L Willard Meds'63

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