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Commentary

What to do about the Canadian Resident Matching Service

C. Ruth Wilson and Zachary N. Bordman
CMAJ November 27, 2017 189 (47) E1436-E1447; DOI: https://doi.org/10.1503/cmaj.170791
C. Ruth Wilson
Department of Family Medicine (Wilson), Queen’s University, Kingston, Ont.; Department of Family and Community Medicine (Bordman), University of Toronto, Toronto, Ont.
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  • For correspondence: ruth.wilson@dfm.queensu.ca
Zachary N. Bordman
Department of Family Medicine (Wilson), Queen’s University, Kingston, Ont.; Department of Family and Community Medicine (Bordman), University of Toronto, Toronto, Ont.
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  • Addressing bias and lack of objectivity in the Canadian Resident matching process
    Tammy Ryan
    Posted on: 24 May 2018
  • RE: What to do about the Canadian Resident Matching Service
    Amit Persad
    Posted on: 17 January 2018
  • RE: Unmatched Canadian Medical Graduates
    Sarah L. Silverberg and Kaylynn M. H. Purdy
    Posted on: 10 December 2017
  • What to do about the Canadian residency matching process
    Janice Willett
    Posted on: 07 December 2017
  • RE: What to do about the Canadian Resident Matching Service
    Christie Diekmeyer
    Posted on: 30 November 2017
  • RE: CaRMS and other forms of torture
    Simon Rose
    Posted on: 27 November 2017
  • Posted on: (24 May 2018)
    Page navigation anchor for Addressing bias and lack of objectivity in the Canadian Resident matching process
    Addressing bias and lack of objectivity in the Canadian Resident matching process
    • Tammy Ryan, Medical Student, The University of Toronto

    The number of unmatched medical graduates has been steadily increasing and has become the focus of much attention in recent months, including in this recent article published in CMAJ, entitled “What to do about the Canadian Resident Matching Service”(1). The discussion has focused primarily on the number and distribution of training positions, with calls to increase the number of residency positions to 1.2 per medical graduate. Indeed, the Government of Ontario has recently funded a number of new positions in order to address this issue.
    What has received less attention however, are the problems with the existing resident selection process. Although there are few studies of the match, there is existing evidence of bias within the system. A study performed at the University of Calgary found that there is significant in-group bias when selecting residents, with preference for applicants from within the institution (2). In the 2017 match, while 80% of male applicants and 83% of female applicants were matched to their first choice discipline, only 62% of female applicants matched to their first choice if it was a surgical discipline, compared to 72% of male applicants (3). In fact, as of the 2016 cohort, there was one surgical residency program in Ontario that hadn’t taken a female trainee in 5 years, according to its website.
    Behind closed doors, many students express frustration at a process they feel is too subjective. This is often attributed to the concept of...

    Show More

    The number of unmatched medical graduates has been steadily increasing and has become the focus of much attention in recent months, including in this recent article published in CMAJ, entitled “What to do about the Canadian Resident Matching Service”(1). The discussion has focused primarily on the number and distribution of training positions, with calls to increase the number of residency positions to 1.2 per medical graduate. Indeed, the Government of Ontario has recently funded a number of new positions in order to address this issue.
    What has received less attention however, are the problems with the existing resident selection process. Although there are few studies of the match, there is existing evidence of bias within the system. A study performed at the University of Calgary found that there is significant in-group bias when selecting residents, with preference for applicants from within the institution (2). In the 2017 match, while 80% of male applicants and 83% of female applicants were matched to their first choice discipline, only 62% of female applicants matched to their first choice if it was a surgical discipline, compared to 72% of male applicants (3). In fact, as of the 2016 cohort, there was one surgical residency program in Ontario that hadn’t taken a female trainee in 5 years, according to its website.
    Behind closed doors, many students express frustration at a process they feel is too subjective. This is often attributed to the concept of “fit”, an abstract assessment of an applicant’s ability to integrate into the existing team. Fit is of course important, but according to CaRMS, “should not be used to indulge personal biases or to discriminate against applicants”. I’ve heard my colleagues describe the match as a “black box” with applicants unable to identify the qualities associated with success. Their frustrations are borne out by the existing data, which reveal a significant element of subjectivity in applicant assessment. Analysis of the plastic surgery match in the United States showed that program directors place importance on AOA Honor Medical Society membership, publications, USMLE Step I score, medical class rank and letters of reference when assessing a candidate whereas Canadian program directors relied heavily on reference letters and clinical interactions (4). More objective measures such as academic honors, awards and publications ranked lower in importance. Interestingly, the identity of the reference letter writer ranked higher in importance than the content. This discrepancy is somewhat to be expected as most Canadian medical schools use pass/fail grading systems which preclude class rankings, however, it seems that the lack of objectivity is due not just to a paucity of data, but to some degree, a failure to acknowledge value in the few objective measures available, including awards and publication record.
    There is also a complete lack of transparency in this process. Students who have sought feedback have been met with resistance, with many programs refusing to disclose any information regarding the review of an applicant’s file. Given that students pay money to apply to these programs and that the stakes of the match are so high, this is simply not acceptable. It also leads one to wonder whether programs fear the scrutiny.
    Dr. Linda Probyn is the Director of Admissions and Evaluation for Postgraduate Medical Education (PMGE) at the University of Toronto. Dr. Probyn says her office has put a number of measures in place to try to ensure fairness in the residency selection process. UofT uses the ‘Best Practices in Application and Selection’ (BPAS), a set of standards developed for this purpose (5). “We run many workshops to train program directors and members of the selection committee on file review and interview” says Dr. Probyn. “Attendance is excellent. We have done our job trying to ensure that this information is passed along.” However Dr. Probyn acknowledges that training is not mandatory and that there is no auditing system in place to ensure that selection committees are following BPAS or adhering to hiring practices outlined by the Ontario Human Rights Commission. “We do the up front training but we don’t go back and make sure that was followed necessarily.” says Dr. Probyn. “We have so many programs that it’s not really feasible to go back and check.”
    In fact, a recent study assessing adherence to BPAS was completed at Dalhousie University (6). The authors found that there were significant weaknesses in the domains of applicant ranking, transparency and knowledge translation with committee members failing to adhere to BPAS standards in all measures of applicant ranking and five of seven measures of transparency.
    There are several steps that could be taken to improve the process. First, all medical schools should adopt BPAS with mandatory training for all selection committee members. Second, PGME or CaRMS-based auditing of program selection practices should be instituted. It is not feasible to audit every program every year but random samples of applicants’ files pre-and post-interview would likely provide enough information to assess objectivity and fairness on a recurring basis. Selection committees should also have access to additional objective information. Options include an examination in the style of the USMLE Step 1 or alternatively, the MCCQE Part 1 could be moved to the third year of medical school.
    Advocates want to fund more residency positions but to support the current system is to support a process that is fraught with bias and crippled by its subjectivity. At the end of the day, these are government-funded training positions and the medical profession has an obligation to ensure that they are being allocated fairly, using objective, merit-based criteria for ranking applicants. “Fit”, should only be part of a larger, more impartial assessment. This is not a problem that will be solved with money and failure to acknowledge all of the issues with the existing match process will only result in a failure to capitalize on any added funds.
    1. Wilson CR, Bordman ZN. What to do about the Canadian Resident Matching Service. CMAJ. 2017 Nov 27;189(47):E1436–47.
    2. Bass A, Wu C, Schaefer JP, Wright B, McLaughlin K. In-group bias in residency selection. Med Teach. 2013 Sep;35(9):747–51.
    3. Canadian Resident Matching Service. 2017 R-1 Main Residency Match report [Internet]. 2017. Available from: https://www.carms.ca/en/data-and-reports/r-1/r-1-match-reports-2017/
    4. Krauss EM, Bezuhly M, Williams JG. Selecting the best and brightest: A comparison of residency match processes in the United States and Canada. Plast Surg (Oakv). 2015 Winter;23(4):225–30.
    5. Bandiera G, Abrahams C, Ruetalo M, Hanson MD, Nickell L, Spadafora S. Identifying and Promoting Best Practices in Residency Application and Selection in a Complex Academic Health Network. Acad Med. 2015 Dec;90(12):1594–601.
    6. Rodger A, Balan M, Epstein I. Applying Best Practices in Residency Selection : A Quality Improvement Project for the Dalhousie Internal Medicine Program [Internet]. The International Conference on Residency Education; 2016 Sep 30; The Royal College of Physician and Surgeons of Canada. Available from: www.royalcollege.ca/rcsite/documents/icre/research-residency-education-r...

    Show Less
    Competing Interests: None declared.
  • Posted on: (17 January 2018)
    Page navigation anchor for RE: What to do about the Canadian Resident Matching Service
    RE: What to do about the Canadian Resident Matching Service
    • Amit Persad, PGY-1 Resident, Neurosurgery, University of Saskatchwan

    To the Editor:

    I read this article on the Canadian residency match with great interest. As a candidate who was not matched to a program after both rounds of CaRMS in 2017, the intricacies and subtleties of the match are an issue near and dear to my heart. 

    I will state that I do not believe that the issues with the match lie inherently with the CaRMS system; rather, they seem to be in the overall culture of residency selection. This falls on not only the selecting programs, but also the candidates themselves. 

    During the application process, candidates canvas for reference letters, write elaborate letters of intent, submit CVs, and compile relevant awards, abstracts and publications. Schools provide programs with compilations of evaluations, with grades summarized as passed and failed rotations. 

    The elements of a successful match seem to be very unclear to all parties. During my conversations with many program directors and committee members, I have found that most do not know what to look for in an applying candidate. Frankly, the consensus is that much of the final selection, at least in smaller disciplines, falls to a gut feeling on the fit of the candidate. This, I must assume, is in large part due to the lack of objective measures of a candidate's overall quality. 

    Traditionally, objective measures might have included a candidate’s grades, but in today’s pass/fail culture of medical training, such measures do not truly exist. R...

    Show More

    To the Editor:

    I read this article on the Canadian residency match with great interest. As a candidate who was not matched to a program after both rounds of CaRMS in 2017, the intricacies and subtleties of the match are an issue near and dear to my heart. 

    I will state that I do not believe that the issues with the match lie inherently with the CaRMS system; rather, they seem to be in the overall culture of residency selection. This falls on not only the selecting programs, but also the candidates themselves. 

    During the application process, candidates canvas for reference letters, write elaborate letters of intent, submit CVs, and compile relevant awards, abstracts and publications. Schools provide programs with compilations of evaluations, with grades summarized as passed and failed rotations. 

    The elements of a successful match seem to be very unclear to all parties. During my conversations with many program directors and committee members, I have found that most do not know what to look for in an applying candidate. Frankly, the consensus is that much of the final selection, at least in smaller disciplines, falls to a gut feeling on the fit of the candidate. This, I must assume, is in large part due to the lack of objective measures of a candidate's overall quality. 

    Traditionally, objective measures might have included a candidate’s grades, but in today’s pass/fail culture of medical training, such measures do not truly exist. Rotation evaluations are often generic, as are letters of reference. Successful research does not indicate a superior clinical candidate; there are, in effect, no true measures of clinical capability of applicants unless they had completed an elective at the interviewing site. Moreover, performance and expectations of a medical student are hard to judge, and may not reflect performance as a resident. One above commenter referred to the rotating internship, which would abrogate this particular concern.

    Many other systems exist, often based on test scores or grades. Of interest to the write, the system in Britain uses a system with many similar elements to our own, but with centralized interviews for each discipline. The decision-making process considers grades, references, personal statements, CV and interviews, and a series of panelists who have not worked with the applicants construct a nation-wide rank list, who then are able to make their selections. While not perfect for the programs, as they have little influence on selecting their most desirable candidates, this system is much more applicant-centered and objective.

    Whether grades and other objective measures are important in assessing a candidate is a completely separate debate, but where the above has left us with is a subjective interview process, meant to assess whether the program would like to work with the candidate with effectively no information on the candidate. It seems as though often decisions are made even prior to this point. It is a system and culture that has moved so far from its roots that it is difficult to know what modifications are needed to repair it.

    Regards

    Show Less
    Competing Interests: Unmatched CMG in 2017 CaRMS
  • Posted on: (10 December 2017)
    Page navigation anchor for RE: Unmatched Canadian Medical Graduates
    RE: Unmatched Canadian Medical Graduates
    • Sarah L. Silverberg, Medical Student, University of Toronto Faculty of Medicine
    • Other Contributors:
      • Kaylynn M. H. Purdy, Medical Student

    To the Editor:

    The Canadian residency match is high stakes for Canadian medical students as it is the only in-country route into clinical practice for Canadian Medical Graduates (CMGs). There is an increasing number of unmatched CMGs in Canada. This trend is of grave concern to the Canadian Federation of Medical Students (CFMS), which represents over 8,000 medical students across Canada. The article by Wilson and Bordman entitled “What to do about the Canadian Residency Matching Service” provides only a glimpse into the complexity of the residency matching system, and we fear that it may lead some readers astray.

    We are concerned with the claim that CMGs face direct competition from international medical graduates (IMGs). In most provinces, CMGs and IMGs apply for separate seats during the first iteration of the match, and direct competition only arises in the second iteration. What is left unclear in the available data is the number of CMGs who applied for each second round seat. Some CMGs in the second iteration might not apply to (or rank) seats, as a result of specialty availability, location of seats, or other factors. One cannot simply look at the numbers of IMG vs. CMG matches, and draw an accurate conclusion.

    The CFMS supports increasing the ratio of 120/100 which facilitates greater student choice, greater flexibility in the system and will lead to less unmatched students. Even a number like this requires nuance; for example, one must consi...

    Show More

    To the Editor:

    The Canadian residency match is high stakes for Canadian medical students as it is the only in-country route into clinical practice for Canadian Medical Graduates (CMGs). There is an increasing number of unmatched CMGs in Canada. This trend is of grave concern to the Canadian Federation of Medical Students (CFMS), which represents over 8,000 medical students across Canada. The article by Wilson and Bordman entitled “What to do about the Canadian Residency Matching Service” provides only a glimpse into the complexity of the residency matching system, and we fear that it may lead some readers astray.

    We are concerned with the claim that CMGs face direct competition from international medical graduates (IMGs). In most provinces, CMGs and IMGs apply for separate seats during the first iteration of the match, and direct competition only arises in the second iteration. What is left unclear in the available data is the number of CMGs who applied for each second round seat. Some CMGs in the second iteration might not apply to (or rank) seats, as a result of specialty availability, location of seats, or other factors. One cannot simply look at the numbers of IMG vs. CMG matches, and draw an accurate conclusion.

    The CFMS supports increasing the ratio of 120/100 which facilitates greater student choice, greater flexibility in the system and will lead to less unmatched students. Even a number like this requires nuance; for example, one must consider seat-specific language requirements. In 2017, 1.026 residency positions were available for every 1 graduate, but the ratio of anglophone positions to anglophone-only applicants drops to 0.986 spots for every one student. The ratio of the numbers of medical students studying in each province to the number of residency seats also varies across the country, with not all provinces having adequate postgraduate seats. According to data from CaRMS, Saskatchewan had the lowest ratio at 0.879 in the 2017 match, and Nova Scotia was the only province to approach the recommended ratio of 1.20, having the highest provincial ratio at 1.157. The competitiveness of the system due to tight and non-dynamic ratios is a significant cause of distress to medical students, and largely responsible for our currently increasing numbers of unmatched students.

    Furthermore, we are cautious of the comparison to European medical schools, many of which do not require previous university degrees for medical school admission. They exist within the context of primary university education with students often entering directly from high school, experience different pressures and norms in university than Canadians, and have different residency requirements. The accumulation of student debt, as well as the different role of medical schools within Canadian society, must be considered in comparison to the European model.

    Finally, it is vitally important to consider the breadth of student motivations and circumstances in their match strategy; steps toward limiting the number of programs to which a student may apply may have significant consequences. For students intending to enter a “couples match” with a fellow colleague, for students hoping for a residency for which each program may only have a few seats, for students interested in more than one career path, or for students who need to apply prior to completing all core rotations, a limitation of applications could significantly harm the student’s chance at a successful match.

    The CFMS is advocating for greater financial support from all organizations, including individual medical schools and postgraduate programs to reduce the burden of the match. To better address the financial burden associated with the final year of medical school, efforts should be made to reduce cost per application, increase interview flexibility to minimize travel costs, and a more objective selection process in which electives are valued less as auditions, and more as opportunities for learning and broadening skills.

    The CFMS is working tirelessly with stakeholders and medical students across the country to address the “unmatched medical graduate crisis” in Canada.

    Show Less
    Competing Interests: The authors are both final year medical students entering the R1 residency match in the 2017-2018 cycle. Sarah Silverberg is file lead, education committee Unmatched Medical Graduates, CFMS. Kaylynn Purdy is VP Medical Education, CFMS.
  • Posted on: (7 December 2017)
    Page navigation anchor for What to do about the Canadian residency matching process
    What to do about the Canadian residency matching process
    • Janice Willett, Associate Dean, Faculty Affairs, Northern Ontario School of Medicine

    To the editor:

    I read with interest the article published in the CMAJ on November 27, 2017 entitled What to do about the Canadian Resident Matching Service. I would like to start by stating that I agree with the importance of the issues raised in this article, and the need for discussion and collaboration around potential improvements in the resident matching system and its supporting structures.

    It is true that the current system has its challenges, which can lead to uncertainty, anxiety, an increasing work effort on the part of everyone involved and, yes, a rising number of unmatched Canadian medical graduates in recent years.

    The application, selection and matching process for more than 3,000 medical school graduates and postgraduate positions is high stakes. At the end of it all, an average 97% of Canadian medical school graduates begin postgraduate training in their year of medical school graduation, while more than 99% begin postgraduate training within the two years following medical school graduation. But there are also other outcomes that matter, and to address them we need to be looking at the entirety of the system. In this regard, we at CaRMS agree with our colleagues throughout the medical education community: together, we can and must do better for those for whom the system has not worked.

    When we talk about the residency matching system in Canada, it is important to note that CaRMS is one of many entities that work together in thi...

    Show More

    To the editor:

    I read with interest the article published in the CMAJ on November 27, 2017 entitled What to do about the Canadian Resident Matching Service. I would like to start by stating that I agree with the importance of the issues raised in this article, and the need for discussion and collaboration around potential improvements in the resident matching system and its supporting structures.

    It is true that the current system has its challenges, which can lead to uncertainty, anxiety, an increasing work effort on the part of everyone involved and, yes, a rising number of unmatched Canadian medical graduates in recent years.

    The application, selection and matching process for more than 3,000 medical school graduates and postgraduate positions is high stakes. At the end of it all, an average 97% of Canadian medical school graduates begin postgraduate training in their year of medical school graduation, while more than 99% begin postgraduate training within the two years following medical school graduation. But there are also other outcomes that matter, and to address them we need to be looking at the entirety of the system. In this regard, we at CaRMS agree with our colleagues throughout the medical education community: together, we can and must do better for those for whom the system has not worked.

    When we talk about the residency matching system in Canada, it is important to note that CaRMS is one of many entities that work together in this area. As the authors themselves outline very clearly, the matters raised transcend the boundaries of CaRMS and encompass provincial governments, learner organizations and medical faculties, along with many other inputs and decisionmakers. At CaRMS, we are responsible for the management of the residency match process, and we do so according to the policies dictated by provinces and faculties. The outcomes of the processes we administer are determined by these policies and the decisions of match participants. For this reason, this interesting and thought-provoking article may have been more appropriately titled What to do about the Canadian residency matching process.

    As Chair of the CaRMS Board of Directors, I can say that CaRMS is eager and willing to work with all our partners across medical education and to bring our knowledge and expertise to bear on this important issue. We look forward to being at the table when our community discusses ways we can work collectively toward better outcomes at a system level – for applicants, for faculties of medicine and, most importantly, for the health needs of Canadians.

    Show Less
    Competing Interests: Chair, CaRMS Board of Directors
  • Posted on: (30 November 2017)
    Page navigation anchor for RE: What to do about the Canadian Resident Matching Service
    RE: What to do about the Canadian Resident Matching Service
    • Christie Diekmeyer, Family physician, University of Ottawa

    As a family physician who trains residents, I am expected to look at the residency applications for carms and rate them. This reminds me every year how Carms is also broken in a different way. The medical schools submit different formats of evaluation and it is cumbersome and sometimes impossible to interpret the different submissions. An "X" on a document in one school might mean the equivalent of a check mark, but often it's guesswork.

    I think that the medical students should be encouraged to have a variety of electives in order to keep their education broad. They should be exposed to family medicine. They should be disallowed from taking only a single type of elective, for if they don't get their choice of residency program, they are seen to be very poor candidates indeed for other ones where they don't have the electives at all.

    Competing Interests: None declared.
  • Posted on: (27 November 2017)
    Page navigation anchor for RE: CaRMS and other forms of torture
    RE: CaRMS and other forms of torture
    • Simon Rose, Fellow, Critical Care Medicine

    I read this article with great interest as someone who has been the CaRMS process twice. While both times the match did result in a reasonable outcome, this is obviously not the case for all applicants, and I look back at the CaRMS process with almost PTSD-like tremor. It is a terrible, expensive, impersonal system, that has deviated far from what I understand to be the original goals of it's inception. Those goals being to provide a fair and equitable, for all parties, method of getting medical trainees into Canadian residency training programs. How much longer are we going to keep propping up a broken system? Is it time to consider that the rotating internship, with all its flaws, might actually be a better pathway for Canadian medical trainees?

    Competing Interests: None declared.
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What to do about the Canadian Resident Matching Service
C. Ruth Wilson, Zachary N. Bordman
CMAJ Nov 2017, 189 (47) E1436-E1447; DOI: 10.1503/cmaj.170791

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