Robert Chu--Unmatched Doctor Commits Suicide

[shady]

IMG's to medicine are the immigrants to politics

Somehow, they're both the root of all evil

[indefatigable]

General - bottom line too few residency positions around - and IMG spots are clearly frustrating to many given the lack of wiggle room in the overall match.  I'd be curious to see the number of residency positions to graduates of AB, BC and Ontario - the major populous provinces besides Quebec.  The Quebec positions aren't even clearly popular within the province and seem to be skewing the overall stats (not to mention inaccessible without French).

 And IMG spots are being increasingly filled by CSAs, but won't ever really be strongly acknowledged since it doesn't fly politically, and some schools seem to benefit from the current status quo.  It's not to say being a CSA isn't a valid option, given a certain degree of chance in the admissions process, etc.. - just not available to that many.  

The MLEs aren't a natural step for many CMGs given the curricular differences and sometimes shortened time frames.   In my limited experience, the curriculum where I am is somewhat Step 2ish whereas US MDs spend two years basically prepping for Step 1.  Also, while individually it makes sense to consider all options, broadly encouraging writing MLEs seems like it may be passing the buck.  Most US residency positions will have a US citizen first policy, so the available positions aren't likely to be the most desirable spots.  Some CMGs from programs with US name recognition would have a better chance overall though.  

But at the center of this thread is Dr. Chu.  Yes - he was young and finishing an MBA, but I wonder what else could have been done to prevent him from going unmatched, not once, but twice?  Systemwide, more spots would help - but what other policies could be put in place - prioritizing home school positions as mentioned previously?  Of course nothing is ever 100%, but there should be confidence in the schools that they are graduating competent individuals and afterwards, given the quantity of public investment as well, situations like Dr. Chu's shouldn't happen.     

 

[NLengr]

From a tax payer POV, an unmatched CMG is a huge waste of government resources, probably a good 250-500k. So having unmatched CMGs is not acceptable. Tax payers paid nothing for IMG educations so if they are unmatched, the tax payer is not out any money. 

I'm not convinced IMG ROS's are the solution to rural healthcare. For one thing, they aren't strict enough if that's the goal. In Ontario, you can work anywhere you can find a job, as long as it's not Toronto or Ottawa. That's a ton of remaining cities that are not rural where most people will end up working. You'd need very strict ROS terms to actually force people to rural areas. On top of that I'm not convinced the ROS provides stable long term care. In my experience, most move on after the ROS is done. It's better than nothing to have then there short term but far from ideal. 

[ralk]

In relation to this story, the focus on IMGs is a bit of a red herring. I'm no fan of the current IMG system, have argued for its reform countless times, and would general prefer it to be more strict towards IMGs in favour of creating a little more wiggle room for CMGs, all for a variety of reasons that would take pages to get into. Yet IMGs aren't to blame here, neither is the dedicated IMG quota system.

Robert Chu went through the 1st round twice, the first time before the cuts to CMG spots in Ontario went into place. While the ratio of residency positions to CMGs has declined, it is still above parity. In these situations, his desired residency spots were taken by other CMGs, not IMGs. If the protected IMG positions were made available to him in some way, perhaps it would have increased his chances and landing exactly the residency he wanted somewhat, but seeing as there was only 8 dedicated IMG Rads positions in Canada in 2015 and 25 CMGs who wanted Rads but didn't get it that year, it's pure speculation that it would have changed his outcome.

He also had two opportunities to apply in the 2nd round, where IMGs have no protections from competing with CMGs. I believe it's pertinent to note that in 2016's 2nd round, there were many English-language positions available in not only FM, but Psych and Rads as well. I have trouble blaming protected IMG spots for his situation when those protected positions weren't in place for some important parts of his application cycles.

I don't want to blame Robert Chu's situation on himself - as I get into in this thread currently discussing the same subject, I have major concerns about the type of advice he was given going into his first cycle, and what kind of support he received after the first time he went unmatched in 2015. I can't say I'm happy with how schools or residency programs seem to treat an unmatched applicant. Yet, I don't want to lionize him either and blame his situation on systemic issues only. We just don't know enough about his circumstances to judge one way or another. To focus specifically on the IMG process makes little sense to me, as we could fully reform that system and still end up with many CMGs in Robert Chu's situation. If it's part of the answer to prevent situations like his, it's a small part and we need to look elsewhere for more effective responses.

[LittleDaisy]

11 hours ago, YesIcan55 said:

I'm really not sure why some people in this post feel they are so high and mighty because they go to a Canadian medical school....I practised interviewing with people this past year who got an offer and I didnt, some got in. I obviously didnt. Not to throw shade at any of them but there was a couple of people who were not strong but got in. One guy got WL the past year with a 27 percentile on his MMI (since his GPA/MCAT were crazy high) and just got accepted, so his MMI score was in the low 30 percentile...for someone with a low preinterview score at this particular school they would need 65+ MMI to get in, so achieving double as the first guy would not be enough to get you in if your preMMI was very low...this is not a post about admissions but just want to humble some of you that there are so many places in the process that involves luck, even getting the interview and then on the actual MMI day too...not much separates an accepted and WL and rejected after getting an interview and what some of you forget that many of the IMGs you speak so badly of got interviews, some multiple, some multiple in multiple years and deserved a spot in your medical school just as much as you...so to treat these specific IMGs like they are so much beneath you is frankly very immature and pretentious. Don't get me started on the comment bashing diversity in Canada...

I am not sure why you mentioned diversity for IMGs. For CSAs, not immigrant-physicians, their tuition is way over our medical school LOC (300,000) at least. The majority of CSAs have supporting parents, physicians or high-earning professionals who pay their abroad education and living expenses, while exercising political power or influencing the media to be more lenient towards CSAs. The admission standards are not as rigorous as Canadian Medical Schools, let alone the clerkship training.

In summary, some CSAs are rich parents' kids who couldn't get admitted to Canadian Medical schools in the first round or after multiple tries, and trying to return to practice medicine in Canada, while being angry at the system of why they can't get the residency place they want, or why the admission rate is sub-optimal.

Regardless of the CaRMS match rate for CMGs. The current job market for a lot of specialists is far from ideal, with a substantial amount of graduating Canadian residents lo-cumming or doing a 3rd year fellowship has difficulty finding jobs in Canada. I don't see why we should recruit more IMGs for FRCPC spots...That certainly won't help the population to get more access to health care, because in the first place, there are not enough jobs! The media is certainly misleading the population, as it keeps targeting: "Blocking CSAs to practice medicine in Canada, while there is a high need of physicians". To be honest, what's the point of training more doctors if the current job market can't keep up with the number of trainees?? Ultimately, that's a waste of money...

For primary care, as stated by the others, the ROS contract is far from strict. A lot of my CMG classmates won't mind practicing a few years in rural years before settling their practice in urban area, since the remuneration is more lucrative and not everyone could find a job in GTA for example. Isn't that what exactly the IMGs are doing in primary care?

Needless to say, I don't think CMGs are feeling mighty and preposterous. I came from a disadvantaged socio-economic background, got admitted to medical school after working 20 hours part-time job while balancing my extra-curricular. I got through medical school with bursaries, governmental loans and part-time job, while still being in debt for the next year years. A lot of us went through clerkship in tears and emotional distress, as we felt almost the bottom of the chain of command sometimes. I just want to illustrate that getting admitted to a Canadian Medical school is certainly a honour, but it's not easy and it involves dedication and hardwork, not just an element of luck. 

 As tax payers invest so much in educating a CMG, I believe that CMG's interests should ALWAYS be protected over IMGS when it comes to residency spots. 

Sorry for being diverted from the original post, I believe that all the Canadian medical schools should adopt some guidelines when it comes to the unmatched candidate. For instance, allowing all CMGs to do the extra 5th year, so they could still do electives and get LORs could be more helpful than 1 year of research or an extra degree. Perhaps, talking to the primary care selection committee, of admitting the unmatched CMGs in the second iteration at least in their home school. Not all Canadian schools are supportive when it comes to the "unmatched" student. 

[Sauna]

Disclaimer I haven't even started med school yet, so I don't know anything. Please criticize the shit out of this post, because everything I'm about to say seems like common sense to me, yet I haven't seen many people talking about it.

Problem: Not enough spots because not enough money.

So assuming we can't get more money, the focus needs to be efficiency.

I don't know much, but I do know that one of the easiest ways to create efficiency and reduce costs is by competition. Keep our current health care system. But why not also add a private sector, creating a 2 tier system. This way we basically have the advantages of both. People are free to choose the system they want (free vs shorter wait times). Physicians can take both public and private patients. Costs are reduced by competition, and we are able to create more spots for CMGs. 

(I don't know enough information to comment on Robert Chu's specific case and what went wrong/what we can do differently to support students)

[ArchEnemy]

21 minutes ago, Sauna said:

Disclaimer I haven't even started med school yet, so I don't know anything. Please criticize the shit out of this post, because everything I'm about to say seems like common sense to me, yet I haven't seen many people talking about it.

Problem: Not enough spots because not enough money.

So assuming we can't get more money, the focus needs to be efficiency.

I don't know much, but I do know that one of the easiest ways to create efficiency and reduce costs is by competition. Keep our current health care system. But why not also add a private sector, creating a 2 tier system. This way we basically have the advantages of both. People are free to choose the system they want (free vs shorter wait times). Physicians can take both public and private patients. Costs are reduced by competition, and we are able to create more spots for CMGs. 

(I don't know enough information to comment on Robert Chu's specific case and what went wrong/what we can do differently to support students)

Please create a separate thread to discuss the pros and cons of a 2-tier healthcare system. Any further discussion in this thread will be deleted

[ralk]

5 minutes ago, ArchEnemy said:

Please create a separate thread to discuss the pros and cons of a 2-tier healthcare system. Any further discussion in this thread will be deleted

Gah, and was just about to post a response. Fair enough, too tangential to the discussion - Sauna, I've sent what I was going to reply as a PM instead.

[1D7]

The issue I have with CSAs trying/matching back into Canada is that almost every CSA I know has come from a financially well off background (usually with a relative/parent working in healthcare). 

Like many of my peers in the same financial background, we didn't have that choice. The majority of those I studied with eventually went on to do something else because of repeated issues during the application process. Close friends of mine literally had to give up their dreams because they couldn't afford to circumvent our system. 

I understand that it's a rigorous process to match back into Canada and on that level I respect all those who do, but IMO it's another layer of social unfairness that shouldn't be there. 

[MedOncologista]

I believe there should be a responsibility on the part of medical schools to offer residency fallback positions for all students who successfully complete medical school, similar to how many internal medicine programs have "default" GIM positions for those unmatched in the PGY4 CARMS match. Students could then decided whether to accept the offered position or try again next year. Candidates with academic difficulty (and I'm in no way implying this was the case here) should be offered remediation, not carried along and left to falter in the residency match. To successfully complete medical school and be unable to access any residency position is unacceptable in my opinion. 

[ArchEnemy]

1 minute ago, MedOncologista said:

I believe there should be a responsibility on the part of medical schools to offer residency fallback positions for all students who successfully complete medical school, similar to how many internal medicine programs have "default" GIM positions for those unmatched in the PGY4 CARMS match. Students could then decided whether to accept the offered position or try again next year. Candidates with academic difficulty (and I'm in no way implying this was the case here) should be offered remediation, not carried along and left to falter in the residency match. To successfully complete medical school and be unable to access any residency position is unacceptable in my opinion. 

This is a great thought, though what discipline would this residency position be in?

Each specialty wants to protect itself, and while Family Medicine might seem like the obvious choice given its duration of training, scope of practice and patient need, you can be assured that the CFPC will lobby hard against this. This is partly why the rotating internship year and accreditation was done away with (although not really, as most Royal College residents continue to rotate off-service almost entirely in PGY-1.

After going through the CaRMS match, I would disagree and state that academic abilities may not matter as much as most applicants would have thought it would.

[Intrepid86]

28 minutes ago, 1D7 said:

The issue I have with CSAs trying/matching back into Canada is that almost every CSA I know has come from a financially well off background (usually with a relative/parent working in healthcare). 

Like many of my peers in the same financial background, we didn't have that choice. The majority of those I studied with eventually went on to do something else because of repeated issues during the application process. Close friends of mine literally had to give up their dreams because they couldn't afford to circumvent our system. 

I understand that it's a rigorous process to match back into Canada and on that level I respect all those who do, but IMO it's another layer of social unfairness that shouldn't be there. 

That is largely irrelevant to the main issues being discussed. Sure, many CSAs come from well off backgrounds, but historically so have a large proportion of Canadian medical students. The professions in general tend to select for such a cohort.

[MedOncologista]

15 minutes ago, ArchEnemy said:

This is a great thought, though what discipline would this residency position be in?

Each specialty wants to protect itself, and while Family Medicine might seem like the obvious choice given its duration of training, scope of practice and patient need, you can be assured that the CFPC will lobby hard against this. This is partly why the rotating internship year and accreditation was done away with (although not really, as most Royal College residents continue to rotate off-service almost entirely in PGY-1.

After going through the CaRMS match, I would disagree and state that academic abilities may not matter as much as most applicants would have thought it would.

I don't necessarily think Fam Med should be default (I'm def of the opinion that fam med is a specialty requiring a specific skill set ), perhaps the positions offered would need to be determined on an as needed basis with medical schools working with their residency programs based on areas of need, budgets, unmatched spots, etc. And agree, this would require buy in from many parties and is easier said than done...but at the end of the day, medical schools invest in students but also profit from them, and they should ensure that candidates who successfully complete their programs are able to become practicing physicians.

[MedOncologista]

22 minutes ago, ArchEnemy said:

This is a great thought, though what discipline would this residency position be in?

Each specialty wants to protect itself, and while Family Medicine might seem like the obvious choice given its duration of training, scope of practice and patient need, you can be assured that the CFPC will lobby hard against this. This is partly why the rotating internship year and accreditation was done away with (although not really, as most Royal College residents continue to rotate off-service almost entirely in PGY-1.

After going through the CaRMS match, I would disagree and state that academic abilities may not matter as much as most applicants would have thought it would.

or perhaps allowing unmatched applicants access to a funded "general" year is another option, which would at least allow them to complete residency rotations likely to be mandatory in most programs as you mentioned, and may ultimately help them be successful in the following year's match...clearly I'm just throwing unrefined ideas out there, but I think we can agree something's going to have to change! Numbers of unmatched applicants are growing yearly, and sadly this problem isn't going away on its own...

[shikimate]

In NRMP there are transitional/preliminary years, which can be a backup for those that don't initially match to their desired specialty.

The other plus is that in many states 1 or 2 post-grad years + completion of all USMLE will allow you to gain an independent license, which will at least allow some scope of practice and income generation. Here in Canada if you don't match to, and complete a specialty you have no right to practice independently whatsoever.

 

Just some thoughts for those contemplating writing the USMLE

 

 

[JohnGrisham]

17 hours ago, BoopityBoop said:

Comments about the article:

1. I agree with everyone here that this was a very unfortunate incidence. That being said, I think there is more to this story and this individual. Not matching for 2 years, while very unfortunate, should not be the sole reason for someone committing suicide. I don't think this is either the victim's problem or the system's problem but I do hope that the school takes this seriously and considers, "did we do everything to support this individual and prevent future individuals from committing suicide?" The school may not have prepared their students for these potential outcomes, the student may not have been mentally equipped to deal with failure, etc etc.

2. I did not appreciate the way that the article made it sound like people who went unmatched is entirely a system's issue. "Chu and a growing number of others denied access to residency have found themselves..." This sounds like ALL residency programs reject applicants. It does not take into account the algorithm, and how luck plays into it all, and how it actually favours the applicants at the end. It also does not take into account how some applicants REFUSE to apply outside of specific location or province, despite repeated counselling.

3. (related to 1st part). I wonder how and why the individual decided to go from radiology to fm/psych to earning an MBA. I wonder how many decisions he made were from his own personal choices, or from strong encouragement from others (i.e. parents, school counsellors, other faculty)

Comment about residency positions (latter half of the comments):

I do think we have a problem in Canada of not addressing the problem of what we define as "IMG". We state that we offer "IMG" positions and set a quota, yet a lot of the competition involves CSAs (canadians studying abroad). This is not only misleading to IMG's, but also to the Canadian public who believe all these IMG positions go to actual immigrant physicians. I suggested this before and I want to reiterate it here: If we want to set a quota for CSA's, we should make this clear and separate this from actual IMG positions. But I doubt that this would fly politically.

A refreshing but minority opinion..when everyone I know is just bashing the system on social media. It absolutely sucks that he killed himself full stop. But there's more to it than a CaRms "system failure". Where the hell was his school with extra support? His social supports? Even if he seemed like he was handling it well on the outside, that's easy to hide when youre forced in a tough situation. There needs to be way more support for unmatched students. Way more. Not "let's just get them into a masters program and clean our hands of them. They'll do better next year".

[JohnGrisham]

5 hours ago, 1D7 said:

 

[zizoupanda]

This is a demonstration of the unjust process of CaRMS. It is becoming exceedingly difficult to match; an unprecedented 60 some students went completely unmatched this year. The system is broken and needs to be fixed. It is laughable that Canadian taxpayers are funding MD education and there is considerable need while dozens of MDs end up going unmatched. There should be 1:1 PGY1 to CMG ratio and all CMGs should be offered some spot before the match opens to IMGs. No one is entitled to a spot in a competitive residency but any CMG successfully graduating is entitled to a residency spot in something somewhere and this should be mandated.

Further the whole electives system is ridiculous; most students choose their electives barely halfway through 3rd year meaning they haven't even experienced half of the specialties they rotate through and if you have any ambition to do anything competitive you have to pretty much dedicate all our electives to that one specialty leaving you with little if any chance to back-up. I find it further insulting that psychiatry wouldn't accept Dr. Chu because he previously showed strong interest in Radiology. I understand there is a fear for transferal but there are ways around this already implemented. There is nothing inherent at the medical student level that makes a particular student excellent in one specialty but not the other. A student with research publications which happens to be in radiology and good medical school record would make an equally excellent psychiatrist, family physician, internist, surgeon,... Force diversification of electives and rank students based on their merit. This is a good op-ed which touches on this and advocates for the return of the internship year about this here: http://www.bcmj.org/editorials/choosing-right-resident. These steps would greatly reduce the absurdly unjust system we are in.

[ellorie]

God.  I would have loathed my life if the rotating internship had returned.  I spent so many years slogging through things I hate to become a psychiatrist - ZERO desire to be "undifferentiated" for a whole other year.  Maybe they could do a transitional year for unmatched folks that would allow you to practice under supervision or something.

Plus, specialties want people who love their specialty.  At the program level, I'd imagine it would be pretty hard to justify ranking somebody who wasn't convincingly interested in psychiatry just because they were a CMG, over an IMG who is dedicated to the field and genuinely loves it.  I don't think that's a personal insult, it just means that we want colleagues who want to practice in our field.

As much as our patients deserve access to physicians, they deserve access to physicians who are dedicated to their specialty, and not just there because they couldn't get anything else.

[JohnGrisham]

3 minutes ago, ellorie said:

God.  I would have loathed my life if the rotating internship had returned.  I spent so many years slogging through things I hate to become a psychiatrist - ZERO desire to be "undifferentiated" for a whole other year.  Maybe they could do a transitional year for unmatched folks that would allow you to practice under supervision or something.

Plus, specialties want people who love their specialty.  At the program level, I'd imagine it would be pretty hard to justify ranking somebody who wasn't convincingly interested in psychiatry just because they were a CMG, over an IMG who is dedicated to the field and genuinely loves it.  I don't think that's a personal insult, it just means that we want colleagues who want to practice in our field.

As much as our patients deserve access to physicians, they deserve access to physicians who are dedicated to their specialty, and not just there because they couldn't get anything else.

I would say though, the threshold for "wanting to be there" at a certain specialty is very different.

I'd definitely agree that psychiatry is special, given the nature of it. 

But family medicine? it is so broad and diverse, that really, there should not be a single family medicine program, save for the very specific focused ones(which are few) that should not at the very least rank the applicant, instead of denying them because "they aren't dedicated to it".   

 

[ellorie]

Yeah.  We don't know that this person wasn't ranked, though, just that he wasn't ranked to match.  Unless he interviewed at a program that went on to have spots in the second round, there's really no way to say.

I also would think that FM is a broad enough field that most people can tailor some kind of practice that allows them to feel relatively satisfied and provide good care.  I'd probably have been a GP Psychotherapist, if I ever ended up in FM for whatever reason.  But I can also appreciate how FPs feel protective of their specialty and don't want to feel like a last resort or a default.

I tend to agree that medical schools should be doing more to support unmatched students, whether that's guaranteeing them a fifth year, or backdooring them into an unfilled spot in an appropriate home-school specialty (though given the vast differences in number of second round spots between medical schools, some people would still be up a creek).  I also think that medical students need to be reasonable in their CaRMS strategies.  I'm not sure what this guy's strategy was, but if he went all in for radiology, that was presumably an informed choice knowing that it was high risk, and that if he did not match, he'd be going uphill in the coming years.  So he is not blameless in all this, if that was his strategy.  You have to be pragmatic about the system that you're in, not operate as if you're in the system you wish you were in.

[indefatigable]

The  thing that gets me is the chanciness of the system.  I believe @rmorelan mentioned that first year was particularly competitive for radiology, whereas the following year wasn't. So basically, it's possible if Dr. Chu had reapplied the following year, he could have got a spot, just due to the increase/decrease in the number of applicants.  Where was the support?  Where was the school reaching out?  

I get that specialties want individuals that are dedicated to their discipline. But, bottom line is competitive disciplines have more applicants than positions.  So unless some fail-safe measure are put into place, this problem is just going to keep growing.  And while I don't believe there's automatic interchangeability between the disciplines, I do think that there is a responsibility of the faculties to ensure that trainees do have avenues open to them if things go wrong.  

As another example, in radiology this year, at UdeM, which in general is considered not easy for students to match to, given its emphasis on pre-clinical & clerkship grades and a radiology based test, I believe @LittleDaisy mentioned an individual matched to a second round spot without any electives in the discipline.  Surely for a discipline like FM, which most Canadian medical school by default teach to, all individuals applying should necessarily be considered and ranked.

There's still a lot of unknowns around Robert Chu's situation, but I really do think more has to be done.   

 

[zizoupanda]

6 hours ago, ellorie said:

God.  I would have loathed my life if the rotating internship had returned.  I spent so many years slogging through things I hate to become a psychiatrist - ZERO desire to be "undifferentiated" for a whole other year.  Maybe they could do a transitional year for unmatched folks that would allow you to practice under supervision or something.

Plus, specialties want people who love their specialty.  At the program level, I'd imagine it would be pretty hard to justify ranking somebody who wasn't convincingly interested in psychiatry just because they were a CMG, over an IMG who is dedicated to the field and genuinely loves it.  I don't think that's a personal insult, it just means that we want colleagues who want to practice in our field.

As much as our patients deserve access to physicians, they deserve access to physicians who are dedicated to their specialty, and not just there because they couldn't get anything else.

I'm not sure I agree. The PGY1 year is already usually quite undifferentiated usually and the internship year would just replace it. "Physicians who are dedicated to their specialty" is a pipe dream and anyone in clinical medicine knows it. I've met countless physicians in clerkship who've openly told they hate their jobs and wish they would've picked a different specialty or another career altogether. That being said, they were excellent physicians nonetheless and fulfilled their patient's needs. At the end of the day a job is a job and there is a serious patient need crisis especially in FM and psych. This isn't the time for picky program directors who have government funded unfilled spots. And yes a CMG with minimal interest should be preferred over any IMG. Every country in this world strongly protects their domestic medical graduates because it costs hundreds of thousands to train them and the public deserves a finished and ready service at the end. CMG should be prioritized.

[ralk]

When we're talking solutions to minimize - but not eliminate - situations like Robert Chu's, the obvious one is to increase the ratio of residency positions to medical students back to its former level of about 1.10. Increasing residency spots would make more people happy, but would be rather expensive and may not help much in the long run given the direction the job market's going for physicians overall. My preferred answer here would be to shift IMG spots to CMG spots to restore the ratio. This would reduce the number of CMGs unmatched while keeping the number of total physicians entering the market stable. This wouldn't eliminate CMGs going unmatched, but it would allow for a bit more margin for error in the 1st round and possibly for more 2nd round spots to be available. Alternatively or in conjunction, the number of graduating Canadian medical students each year, which has risen substantially over the past two decades, could be cut back slightly.

I dislike bringing back a full rotating internship. It would be a remarkably inefficient year. Current PGY-1 years may not be focused, but they're far from being undifferentiated. Most specialties only have a CTU rotation in common, while most off-service rotations have specific relevance to their main specialty. Every resident would be set back the better part of a year relative to their current training with a rotating internship. It also just delays the decision-point of residency. How would someone prove they want a specialty after their internship? Presumably by making contacts in the field, doing research or other work with those specialists, using whatever elective time they have in that field... which is the system we have now. It's just a year later. The supposed advantage of the rotating internship is that people who do not go onto a specialty get a GP license afterwards, essentially allowing them to practice as a primary care provider like most FM docs. I don't think that's safe anymore. A lot has changed in the 25 years since the rotating internship was eliminated. Medicine is far more complex, both in terms of the medicine and in how healthcare is organized. A GP with only a rotating internship would have less training in a primary care, outpatient setting than a FM resident after their PGY-1 year. That's nowhere near close to adequate for independent, unsupervised practice, at least not as medical school and residency programs are currently set up.

I'm intrigued by the notion of forcing schools to provide a residency position for unmatched candidates, as we desperately need them to have more skin in the game when it comes to their own unmatched students that they've given the greenlight to enter residency. Schools need a stronger incentive to do well by their students. However, this does create some poor incentives for students. Let's say I'm a U of T student who wants to stay in Toronto, where all the residency spots are competitive. If I'm willing to take FM, where I'll likely end up, it doesn't give much incentive for me to push for a spot in a less-desirable location when I can essentially default into a desired spot.

I think what medical schools do to prepare students for residency applications is where a lot of good could be done. First and foremost is simply informing students of the current realities of the match and guiding them towards it more deliberately with some degree of personalized assistance. It boggles my mind that I had to figure out how the match worked for myself, piece together the important elements of an application by talking to dozens of people (none of which were serving in an official capacity with my school), and then explain these to some of my classmates as late as in our final year of study! This isn't a particularly hard thing for schools to change, but there seems to be little interest in doing so effectively. More dramatic moves - like changing the nature and/or timing of pre-clerkship classes, clerkship, and electives - I think could be helpful, but are far harder to do and come with their own pros and cons that are too much to get into in this already-overlong post.

Edit - Removed an argument that, on reflection, was difficult to justify.

[ellorie]

2 hours ago, zizoupanda said:

I'm not sure I agree. The PGY1 year is already usually quite undifferentiated usually and the internship year would just replace it. "Physicians who are dedicated to their specialty" is a pipe dream and anyone in clinical medicine knows it. I've met countless physicians in clerkship who've openly told they hate their jobs and wish they would've picked a different specialty or another career altogether. That being said, they were excellent physicians nonetheless and fulfilled their patient's needs. At the end of the day a job is a job and there is a serious patient need crisis especially in FM and psych. This isn't the time for picky program directors who have government funded unfilled spots. And yes a CMG with minimal interest should be preferred over any IMG. Every country in this world strongly protects their domestic medical graduates because it costs hundreds of thousands to train them and the public deserves a finished and ready service at the end. CMG should be prioritized.

After the second round this year, neither psychiatry nor family medicine had ANY unfilled spots in English Canada.  Again, I suspect that these people are being ranked, just not as highly as others.  They are probably, in the first round anyway, being ranked behind other CMGs whose first choice is that specialty.  And probably sometimes behind IMGs in the second round as well.

My experience of clinical medicine has not been the same as yours.  I have met very few physicians who have told me that they "hate their jobs"  I don't remember that being a prominent part of my experience in clerkship either.  I met residents who hated their lives, but that was more related to other factors.  And a few residents who didn't like their specialties.

Plus, the nice thing about PGY1 is that you have to rotate off service, but you don't have to care anymore.  No trying to impress people who aren't in your specialty, no worrying about evaluations in things that are irrelevant to you.  And being able to feel secure that after you slog through it, you'll be in your specialty forever.  No more doubt or waiting or gunning.  And, for me, no more surgery ever   I did eight blocks off service (mainly relevant-ish stuff like neuro, family, and emerg), and five blocks on service.  Pretty dissimilar to what a traditional rotating internship would have involved, to my understanding.

Don't get me wrong, when I was a PGY1, I took good care of my patients.  But unlike pre-CaRMS, I focused on that 100%.  I didn't have to go home and read about useless stuff, or look like a superstar all the time.  The weight of stress that was lifted off was huge.  For people like me, who always knew what they wanted to do, it would really suck to have to wait longer and longer.