It's the uncertainty principle, writ large, on the medical residency stage.
Angered by a proposal to put graduates of Canadian and foreign medical schools into 1 competition hopper and buffeted by conflicting reports about the future process for determining residency positions in Canada's postgraduate medical training system, students are pleading for a 1-year moratorium to sort out the implications of proposed reforms.
At issue are the consequences of a decision by the Association of Faculties of Medicine of Canada (AFMC) to, de facto, jettison the traditional 2 iterations of the annual residency match undertaken by the Canadian Resident Matching Service (CaRMS), starting in 2007. Historically, the first round of the match of student to discipline and training program has been restricted to recent graduates of Canadian medical schools, while the second iteration was for graduates unmatched in the first round; graduates from previous years; physicians seeking to change specialties or residents seeking to change location; and international medical graduates (IMGs), both Canadian and foreign-born.
But at its annual general meeting earlier this spring, the AFMC declined to approve a 2-iteration match, ostensibly on the grounds that it hoped to strike a Memorandum of Understanding (MOU) with the provinces. Under this so-called “embedded parallel” match, there would be 1 national competition for graduates of Canadian schools and another for IMGs. Every Canadian graduate would be guaranteed a residency spot.
The intention, says AFMC President and CEO Dr. Nick Busing, was to create “equitable access” for all IMGs by creating a single nation-wide match for all available IMG residencies, using standardized criteria.
“We're not talking about putting more positions into the system. We're talking about preserving slots for Canadians and encouraging and pushing the provinces to run a parallel match using the existing IMG slots.”
Measures to ensure equitable access for IMGs must be adopted in light of several Canadian Charter of Rights and Freedoms challenges working their way through the system that contend the existing system is discriminatory, Busing adds. “AFMC also wanted and wants to be sensitive to government and societal needs and expectations.”
But as of June 19, the MOU has not yet been reached, nor do all provinces appear onside, and, in the absence of a deal before July 1, CaRMS has indicated it will have little alternative but to launch the process for the 2007 match by throwing everyone into a 1 competition-hopper, unless, of course, the AFMC reconsiders its position (which Busing says is a possibility). Moreover, even if an MOU is reached, there's a very real chance the system will be fragmented, as Quebec and Manitoba have indicated they won't offer parallel matches, so it's entirely possible the end result will be a series of separate provincial competitions, in which the criteria and the process vary province-by-province.
Yet anything less than separate, nation-wide programs for Canadian graduates and IMGs “does not serve anyone,” argues Canadian Association of Internes and Residents (CAIR) President Dr. Jerry Maniate, who recently accepted a clinical fellowship in thoracic oncology at the University of Toronto. “It's moving away from a pan-Canadian approach to human resource planning to one that's just centred around universities and perhaps even provinces, looking out for what's best for them, but not necessarily what's best for the country and Canadian society as a whole.”
Canadian Federation of Medical Students (CFMS) President Andre Bernard argues it would also leave students subject to the “fickleness” of provincial governments and charges that medical school deans are abdicating a responsibility to their students. “Until this point, we've had the deans, kind of as a consequence of restricting the first round of the match, serving as stewards over the process and keeping the integrity of it together as a national match.”
The CFMS and CAIR also argue that anything less than guaranteed spots for Canadian grads is untenable and a waste of taxpayer dollars, given existing subsidization of medical education. They say the plan would limit interprovincial mobility and student flexibility to obtain specialty training if a program is not offered in their province and compromise the quality of education by constraining exposure to different professors and pedagogical techniques. In addition, it would exacerbate pressures on medical faculty, who are already overwhelmed by increased enrolments and would be hard-pressed to provide even more administrative and cultural instruction if there was a further influx of IMGs, thus compromising the amount of individual instruction any resident might receive.
The uncertainties have left students apoplectic, says Bernard, who accepted an anesthesia residency at Dalhousie in last year's match. “It's entirely frustrating for us to be sort of the guinea pigs of this process, when we have the most legitimate stake, because we're all co-creators of Canada's health care system in the future.”
It's vital the issue be resolved to prevent fragmentation of the residency match, as well as ensure there's a “balance” in the rights of Canadian grads and IMGs, says Canadian Medical Association President Dr. Ruth Collins-Nakai. “We need to get this right. The future of all our young physicians and for that matter, the future of our profession, is at stake.”
If a parallel match is adopted to ease access for IMGs, it's equally important that “additional slots” be established to handle the anticipated influx, she adds. The provinces say they haven't the resources to create those slots, so the CMA is urging that the federal government create and fund a 1-time program to establish residency spots for 200 IMGs over the next few years.
Many of those spots could take the form of “visa buy backs” of slots now purchased by foreign governments on behalf of students being trained in Canada, Collins-Nakai says. “We recommend a hold on the visa trainee positions, that the federal government buys those positions at the foreign government level in the different schools in order to accommodate some of the IMGs already in the country. So we're not recruiting from other countries. But we do have people in the country and we felt if we could get them into the system, it would help alleviate some of the shortages, especially of family physicians.”