What to do about the Canadian Resident Matching Service

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

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.

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.