A few years ago, a shortage of postgraduate training positions was setting off alarm bells within the medical establishment. Now new bells are going off because many of these same slots are remaining unfilled, and the ringing is particularly loud for family medicine (see Commentary, page 1419).
Figure. What would Marcus Welby do? Photo by: ABC
A record 53 of the 1260 available residency slots remain unfilled after the second iteration of the 2002 residency match; 188 positions — another record — were unfilled following the first round. (The first iteration of the 2000 match ended with 111 positions unfilled, and all but 15 were gone after the second round. This climbed to 153 and 48 positions, respectively, in 2001.)
The 2002 results stunned some family medicine programs. “We were devastated,” said Linda Kirby of Newfoundland's Memorial University, where 9 of 20 family medicine positions are vacant. “We knew the numbers would be down, but we never expected that half of our positions would go unfilled.”
Family medicine accounts for 83% (44) of positions vacant after the second iteration. The only other specialties with more than 1 vacant spot are psychiatry (3), obstetrics (2) and pathology (2).
The University of Toronto, which has never had a vacancy before, has 5 in family medicine. “We were very surprised,” said Dr. David Tannenbaum, the program director. “This is brand new for us — Toronto has always been a popular place to be.”
Sandra Banner, executive director of the Canadian Resident Matching Service (CaRMS), hopes the news will be better next year. “I think we've hit bottom in terms of producing small undergraduate classes, and the impact of the increases in enrolment we've seen recently will start to be noticed next year.”
But the vacant family medicine positions leave Tannenbaum worried. He blames issues ranging from the uncertainties posed by primary care reform to the fact that some medical students — particularly in Ontario — are worried about debt loads and the income potential in family practice. He is also concerned that undergraduates may not be receiving a true picture of family medicine at medical school, where most of the training is done by specialists. “The message may not be getting through,” he says.
Matthew Erskine, president of the Canadian Federation of Medical Students, agrees. “Students enter medical school wanting to become ‘doctors’ and leave wanting to be pediatric oncologists and hepatopancreaticobiliary surgeons,” says Erskine, who graduates from McGill this spring and will enter a general surgery residency at Dalhousie. “Obviously, the experiences a student is exposed to during the 3 or 4 years of medical school play a crucial role in shaping career choices. Not only is the formal curriculum, with varying degrees of exposure to different types of family practice, important, but so too is the unwritten curriculum students are exposed to as they undergo socialization in the fraternity of medicine.”
Erskine also says it is no coincidence that certain schools produce higher proportions of family medicine applicants than others — this year's range was from 15% (McGill) to 52% (McMaster). “The prevailing institutional attitudes toward family medicine have a large impact on career choice,” he says.
And he says the 2002 results may be an aberration because the highest number of residency positions in 6 years (1260) converged with the lowest number of participating graduates in recent memory (1117). This produced a record student-to-position ratio of 1:1.13.
Banner says these numbers mean that a positive spin can still be put on this year's match. “What I would say is that there is room in the system when there wasn't any before,” she says, “and this means there is more choice.” She also issued an open invitation to Canadians who have trained abroad to apply (see accompanying article, page 1450).
CaRMS says the University of Manitoba finished the match with 11 family medicine positions unfilled, including 6 in rural medicine, but program director Dr. Jill Kernahan says the school still filled the same number of positions as last year and it expects interest will grow as medical school output increases. Tannenbaum is not as optimistic — applications for the U of T's family medicine program declined by 10% for the 2002 match.
But no one knows what the future holds. “These numbers are a real cause for concern,” says CMA Past President Hugh Scully, who is cochairing a federal task force on medical human resources.
Scully, a cardiac surgeon, thinks a “disconnect” is developing between the direction primary care reform is heading — the need to provide 24/7 coverage, for instance — and the direction new graduates want to take. “What the match says to me is that many people are not interested in going into this type of practice.”
And he wasn't surprised that some programs had numerous vacancies. “The absence of resources in Newfoundland is a very real issue,” he said, “and new graduates will be aware of it.”
Scully thinks family medicine must actively court medical students during this buyers' market, and suggests that it may need to pursue the “role-model mentor” model that drives specialty recruiting.
Erskine says medical students train in at tertiary care centres and “many find the thought of then working alone or in a small group practice, treating patients with chronic and, for lack of a better word, more mundane, illnesses, less than appealing. Obviously this is not an accurate description of family practice, yet it reflects the way many students view it.”
Views like that no longer surprise Tannenbaum, who says FPs have to respond by becoming salespersons. “This is a tremendous career,” he says. “We have to get that message out.” — Patrick Sullivan, CMAJ
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