Colleges contemplate revising post-graduate medical education

The Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada are nearing the end of a 2-year national consultation that could redefine post-graduate education for future generations of Canadian medical students.

The 2 colleges launched the Core Competency Project in 2005 to determine if post-graduate training should be redesigned to cover a range of “core competencies” and to allow students greater flexibility in choosing specialty disciplines. The project involved exhaustive consultation and research, says Dr. Jason Frank, associate director of education for the Royal College. In addition to a national survey of medical educators, students and residents, the project obtained comments from more than 100 groups in the medical community and reviewed more than 5000 relevant articles.

Project leaders will present the results of the consultation at the Royal College's national conference in Winnipeg, Sept. 27–29. As of press deadline (Aug. 6, 2007), it had not been decided whether the project report would include firm recommendations on restructuring post-graduate training, or merely a summary of the findings of the national consultation. Either way, Frank predicts the report will spark a vigorous debate on the future of post-graduate education.

“This represents a fundamental re-think about how we structure the residency portion of medical education in Canada,” says Frank.

The medical community has for years expressed concerns about the current post-graduate training system, which puts enormous pressure on medical students to select and prepare for specialties early in their training, Frank says.

The emphasis on specialization means most medical students are forced to focus early on electives that will help them when it comes time to apply for a residency program through the Canadian Resident Matching Service (CaRMS), Frank says. This raises the concern that students are sacrificing important general medical knowledge and training in pursuit of specialty training, he adds.

There seems to be consensus in the medical community that regardless of specialty, all doctors should be trained in the most basic medical services, such as performing a physical examination and delivering a baby, Frank says. The debate at the September meeting will centre on how best to build core competencies into post-graduate training, he adds.

The current system has also made it difficult for students to switch specialties midstream, he says, because of the limited number of specialty resident positions.

Although the Core Competency Project has yet to produce a report of any kind, medical students, faculties of medicine and educators have hotly debated its focus. Some medical students are worried that a renewed focus on core competencies could add to the length and cost of medical education.

“Students entering medical school today are older and we've got a little more debt heaped on us,” says Sonya Abdulla, vice-president of education for the Canadian Federation of Medical Students. “The sooner we can get out into the workforce, the better.”

Most students do not want a return to the rotating residency system that was in place up to the early 1990s, says Abdulla. However, many would agree that covering an array of core competencies as part of any medical education is a positive step, she says. “We can accept that there is a certain set of skills that any good doctor needs regardless of specialty.”

The broad scope of the Core Competency Project has some in the medical community anxious for a more detailed and focused explanation of exactly what the 2 colleges would like to achieve and how they intend to achieve it.

“It's not entirely clear what the goal of the project is,” says Dr. Nick Busing, president and CEO of the Association of Faculties of Medicine of Canada. “My sense is that having done all this important work, we still don't know what the real issues are that the project is trying to address.”

Busing says educators and opinion leaders within the specialty disciplines regularly debate core competencies, and what steps need to be taken to build them into a solid medical education. However, there is no consensus on exactly what constitutes a core competency, or how important it is to include it in every discipline.

Busing says core competencies could include the ability to incorporate information technology into day-to-day practice or to communicate effectively with patients and other doctors. A proposal to identify a standard array of core competencies and a plan to include them in all post-graduate medical education is likely to spark a heated debate, he notes.

“If this is a model in which students enter into a defined number of core streams before broadening out into medical specialities, that would be a fundamental re-think,” Busing says. “That could be a real challenge for a lot of people in post-graduate education to get their minds around.”

Busing also challenges the suggestion that students are under too much pressure to specialize early in their post-graduate training, and that the system prevents many from switching specialties in midstream. Busing says the number of students requesting the opportunity to switch is relatively low, and there has been no increased demand to make the existing system more flexible.

“I think if you look at the number of dissatisfied students who have decided they wanted to switch, it has not gone up significantly,” Busing says. “There just isn't any solid evidence that the current system has increased that number.”