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Healthy Debate (May 25): Medical residency mismatch: number of unmatched Canadian medical grads...

Medical residency mismatch: number of unmatched Canadian medical graduates reaches all-time high

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The number of Canadian medical graduates unmatched with a residency training program has reached unprecedented levels, with students and faculty concerned about the growing gap between students and necessary training.

Since 2009, the number of unmatched Canadian graduates has been steadily increasing, moving from 11 in 2009 to 68 this year.

“This represents 68 students who have spent on average eight to 10 years of undergraduate education to become physicians, incurring great debt, and utilizing taxpayer dollars to facilitate their education,” says Mel Lewis, a student affairs associate dean at the University of Alberta.

“There’s a lot of anxiety,” says Franco Rizzuti, president of the Canadian Federation of Medical Students. “Students are starting to grasp at straws, trying to understand what’s going on.”

A total of 64 training positions also went unmatched, including four in Alberta, two in Ontario and 58 in Quebec.

To be able to practice medicine, all medical students need to complete a residency program in an area of specific clinical medicine, such as family medicine, surgery or psychiatry. Students compete with each other for a residency program through an application and matching process administered by the Canadian Resident Matching Service (CaRMS). This follows a very similar process to the one used in the United States.

From a broader societal perspective, those who track health human resources nationally say there’s no reason to panic: 68 unmatched participants is a small fraction of the nearly 3,000 Canadian medical students who took part in this year’s match, and the 64 positions that remained unmatched typically end up filled.

On an individual level, although being unmatched is stressful and a loss of a year, historically, virtually all unmatched students find success in subsequent years.

Matching for a physician’s future

In many ways, the Canadian medical residency match isn’t all that different from online dating: following a written application and interviews, students and training programs rank one another and an online algorithm is used to identify potential matches. In essence, both parties need to “swipe right” to make a match.

However some training programs have fewer positions than applicants and other programs don’t have sufficient applicants of interest for their positions.

There are two iterations of the match; the first is reserved for newly-graduated Canadian medical students. Students unmatched in the first round, as well as international medical graduates (including Canadian citizens studying in medical schools abroad) and Canadian medical graduates who went unmatched in previous years, join the second iteration.

A student may choose to apply to only one program – training in cardiology at McGill or paediatrics at the University of British Columbia, for example – or rank multiple programs in multiple locations.

Rizzuti says students apply to an average of 18 programs – nearly double the number of program applications compared to a decade ago. CaRMS data show there were 128,334 applications to 644 programs, up nearly five percent over last year.

Historically, the match has had more wiggle room in the first round and a greater likelihood that Canadian medical graduates would match with their top-ranked training program.

In 2009, the ratio of Canadian medical graduates versus residency positions was 1:1.12.

“There was a little bit of a buffer in the system, a few more spots than there were Canadians applying. That gave some flexibility and allowed international medical graduates to come into the system,” says Genevieve Moineau, president & CEO of the Association of Faculties of Medicine of Canada.

In 2017, the ratio shrank to 1:1.026. “Now instead of having a 10 percent buffer, you’ve got a 2.6 percent buffer. It’s really, really, really tight,” Moineau says.

Mismatch in student interests versus training needs

The number and types of training positions available are usually decided by governments and medical schools, based on planning for population needs and medical school capacity. The exact process varies by jurisdiction, with population needs beginning to drive the process in some provinces.

The overall number of residency positions available across Canada has remained largely unchanged since 2013, when it rose above 2,900. (Last year, the quota was 2,970. This year it was 2,967.)

But the number of graduates participating in the match has outpaced growth in the quota. In 2013, there were 2,633 Canadian medical graduates participating. This year, that number rose to 2,810, a slight dip from 2016, when 2,836 medical graduates were looking for a match.

“There has been a decline in residency spots, most notably in Ontario, with no commensurate decrease in medical student enrolment, squeezing the supply and demand quotient even further,” Lewis says.

Exacerbating this tightened ratio is a long-standing mismatch between the personal career interests of medical students and where governments have funded training positions based on their view of future physician need.

Some say it is an unreasonable expectation that every medical graduate should have the residency of their choice.

“It’s, in part, the mindset,” says Ivy Lynn Bourgeault, who holds the Canadian Institutes of Health Research Chair in Gender, Work and Health Human Resources and is lead coordinator of the pan-Canadian Health Human Resources Network. “We should go where the need is. That should be inculcated in medical schools.”

This year, graduates ranked dermatology, plastic surgery and emergency medicine highest, with demand for training in those disciplines far outstripping the supply of training spots.

By contrast, after the first and second rounds of the match, opportunities in family medicine, psychiatry and laboratory sciences (which includes different types of pathology) were left unfilled.

This year’s match also saw a slight reduction in the number of students prioritizing family medicine and more students ranking internal medicine, creating a wrinkle for students who could not have anticipated this shift and failed to give themselves options in their rankings.

Applications from international medical graduates (IMGs) may also be a factor, putting more pressure on Canadian students looking to match in the second iteration. The number of IMGs participating in the match peaked at more than 3,100 in 2014, when the Objective Structured Clinical Examination became a mandatory requirement for all IMG applications outside of Saskatchewan. This year more than 2,400 IMGs participated.

But Bourgeault argues that IMGs are not the problem, citing forthcoming research. “We under-utilize immigrants,” she says, noting that many of the IMGs who find success in the match process are willing to go where others won’t.

Migration out of Quebec

Migration within the country is also playing a role, with students in Quebec opting for residencies in other parts of the country. While bilingual students can rank positions in Anglophone Canada, English-speaking students can’t hope to place with a training position that requires French.

This year’s match shows that while Quebec had 58 unfilled positions, it had only eight unmatched graduates, compared to 35 unmatched graduates from Ontario, 20 from Alberta and five from Atlantic Canada.

“If students in Quebec are now taking positions outside of Quebec, and students who are hoping to match are not able to, there’s a disparity there,” Moineau says. “The tighter the ratio, the more variables of the playing field, the more challenging it becomes to match.”

“Understanding why Quebec graduates don’t want these positions is key,” Bourgeault says.

To deal with its perceived physician shortage, Quebec has introduced health care reforms, including actions focusing on physician workload, as well as regional medical resource plans that restrict where and how a physician can practice.

2014 survey among Quebec medical residents found that 47 percent of those leaving medical residency for professional practice did not have a position two months before finishing their training. Among these residents without a position, 27 percent said they intended to leave Quebec. More than three-quarters of respondents said they believed there were not enough job opportunities for the number of trainees.

Planning for the future

Unmatched Canadian graduates have two choices: they can opt to graduate and spend their time as they choose (perhaps doing a master’s program or research) until the match re-opens the following year, or they can defer graduation and instead take more electives as a medical student.

Neither is ideal, Rizzuti says. “The former automatically puts you into debt repayment as you’re no longer a student. The latter, where they stay another year, means students are paying another full year of tuition. For Ontario, that’s $25,000 to $30,000.”

“Solutions are complex,” Lewis says. “We need to have a better understanding of the types and number of physicians we need in Canada to help inform our students around their career planning and inform educators around curriculum planning. We need to ensure their are adequate residency spots available to our students with consideration of how many undergraduate medical students we should be graduating.”

Moineau co-chairs a national physician resource planning committee that’s currently developing a tool to help forecast future physician needs, which will help make the case for changing student admissions or residency quotas to better align.

“We feel strongly that we need to move to being in a society where we have the right number, mix and distribution to meet societal needs,” Moineau says.

“This is where everybody needs to advocate to government that we need to have appropriate, long-term health human resource plans in place,” Rizzuti says. “There needs to be a broader conversation to be sure there’s proper alignment in all the steps in training.”

Such a call is not new, dating back to at least the mid-1990s, with significant efforts undertaken to do such planning by governments, medical schools and medical associations.

Students may also need more career counselling in the lead up to the match, Moineau says, as disciplines like surgery or laboratory sciences have become segmented, forcing students to choose a sub-specialty, like neurosurgery versus cardiac surgery, which may prove strategically disadvantageous.

Health human resource planners may also need to take a closer look at how provincial funding and politics are influencing graduates’ choices about where to go for residency training.

Training may also need to be revamped to ensure students get exposure to different disciplines, Rizzuti says, as many graduates are still turning away from rural and remote residencies, which could speak to their experience learning in mostly urban medical schools. The interest in family medicine as a first choice has also fluctuated markedly in the last 10 to 20 years.

Opening more training spots for physicians is not the answer, Bourgeault says. In the health system as a whole, there are already a number of health care professionals whose skills are under-utilized, including nurse practitioners, pharmacists, physiotherapists and others.

Instead, medical schools should be thinking about how to attract and prepare the students they need for the positions they’ve got, and continue to adjust the number and mix of residency spots to better meet societal need.

“We need to do that better,” she says. “We have a distribution issue, we don’t necessarily have a numbers issues.”

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