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[offmychestplease]

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[MasterDoc]

It may be due to the fact that Family Med act as gatekeepers here and you need a referral to go see a specialists. Where else in the states as long as you have the funds you can go see any physician right away. 

One thing to note is that FM in Canada can also act as hospitalists and they generally have a much larger scope of practice. Hospitalists positions in the US are usually held by IM.

[indefatigable]

On top of the "gatekeeper" rule difference, which also results in more US outpatient-focused internists, US FM education is longer (3 years) with lower renumeration than almost every other specialty.  Given the much higher costs of US med ed, this creates pressure to pursue higher-paid specialties, where the job markets are often (but not always) stronger than Canada.  Canadian med education is also more focused on the "GP model", whereas US has focused more on basic sciences and specialty education.  

There's also about almost twice as many IM residency positions in the US than FM, whereas in Canada there's about three times as many FM spots than IM, with FPs practicing as hospitalists in Canada, but much less in the US, as mentioned above.

Historically, in both Canada and the US, FM has been seen as a "default" choice, although this has changed a lot, at least in Canada.  Still, many often initially view FM as less prestigious and rewarding, although there's considerably more spots than most other specialties, which means many do ultimately end up in family.  I think in Canada given the generally-speaking more difficult specialty job market, with longer training, and less pay differences, more ultimately may also end up choosing FM too.  

 

[James Nystead]

Also to add to the discussion, 40+% of CMGs match to FM but a good % of those that do, match have FM as a 2nd choice specialty (aka backup to a more competitive specialty like Derm, Emerg, Surgical subspecialties, OBGYN) and matching FM is not so much a want/desire, as it is something imposed onto them as they would rather match something than not match at all. 

 

In the US, IM and Peds act as primary care physicians as well. IM and Peds training is also only 3 years v.s. 4 (really it's 5 with GIM and Gen peds "fellowships") in Canada. 

[indefatigable]

36 minutes ago, James Nystead said:

Also to add to the discussion, 40+% of CMGs match to FM but a good % of those that do, match have FM as a 2nd choice specialty (aka backup to a more competitive specialty like Derm, Emerg, Surgical subspecialties, OBGYN) and matching FM is not so much a want/desire, as it is something imposed onto them as they would rather match something than not match at all. 

In the US, IM and Peds act as primary care physicians as well. IM and Peds training is also only 3 years v.s. 4 (really it's 5 with GIM and Gen peds "fellowships") in Canada. 

For sure some do match to FM, not as their first choice, but about 80% first round FM matches last year had FM has first choice with emerg, IM, psych, peds, anesthesia..  being the top alternate first choices (source slide 26) and probably higher excluding Quebec (slide 28).  

[rmorelan]

also a small fraction of your class? what year are you in? I only mention that as the general desires of classes tend to shift - particularly once clerkship hits and see what the job is like more. Things are less abstract then and you understand the jobs better (with out joking about many of the top students in my class wanted FM for entirely logical reasons in the end - including some with PHDs ha in fact. Working 5 extra years to earn 100K more - and even that is debatable - didn't make sense to them - particular when you consider that extra money was coupled with simply working extra hours - backed up in large part on the CMA surveys of various fields). 

In the US as someone mentioned you need less family medicine docs as some fields are also primary care. It also pays a lot less, and takes longer to get - not exactly motivating. The US situation there is also stupid but that is another discussion. 

Don't get the idea that in Canada most FM docs don't want to be there. That isn't the case at all - and the math backs that up. Even say looking at surgery as a whole with lower match rates - what fraction of all doctors go into surgery (it is about 1/7 for all fields), and of those roughly 2/3 that attempt it get into surgery. That gives at worst 200 people backing up in something and assuming all go into FM that gives you also about 1/7 of all family doctors being "displaced from surgery" etc being extremely conservative there (non try again, or back up into anything other than FM which of course is wrong). Many of those other fields with high unmatch rates are also relatively tiny in terms of spots. So there are many other fields but with family medicine and IM being the bulk of all positions and also ones with a high match rate you can basically derive on the broad scale how many want things, and where they go giving you that most people in FM actually wanted to be there. For good reasons I will add but I am not trying to sell any one field over the other - but I don't find myself having to say that people in family medicine didn't settle etc. I have said many times on this forum that I am annoyed that didn't like family medicine personally as a career but otherwise I probably would have gone that route.

anyway ha - I will tell you that for many when you get closer to CARMS getting a very nice job with great lifestyle and a very solid paycheque quickly starts to look very nice (and roughly 200 less very long all nighters doesn't hurt either). That isn't settling - it is realizing that doing things that are harder just because they are harder is kind of stupid when it comes to career planning. Yet many type A med students are by default stuck in that mode. Doing harder things because you decide that is really want you want will always make sense. A least make it an actual choice though and not go on autopilot. 

Edited October 20, 2020 by rmorelan

[indefatigable]

17 minutes ago, rmorelan said:

Don't get the idea that in Canada most FM docs don't want to be there. That isn't the case at all - and the math backs that up. Even say looking at surgery as a whole with lower match rates - what fraction of all doctors go into surgery (it is about 1/7 for all fields), and of those roughly 2/3 that attempt it get into surgery. That gives at worst 200 people backing up in something and assuming all go into FM that gives you also about 1/7 of all family doctors being "displaced from surgery" etc being extremely conservative there (non try again, or back up into anything other than FM which of course is wrong). Many of those other fields with high unmatch rates are also relatively tiny in terms of spots. So there are many other fields but with family medicine and IM being the bulk of all positions and also ones with a high match rate you can basically derive on the broach scale how many want things, and where they go giving you that most people in FM actually wanted to be there. For goods reasons I will add but I am not trying to sell any one field over the other - but I don't find myself having to say that people in family medicine didn't settle etc. I have said many times on this forum that I am annoyed that didn't like family medicine personally as a career but otherwise I probably would have gone that route.

I don't think surgery is that high on the list of alternates first choice specialties for FM matches, at least in the first round.  According to the link I put in the post above, 929/1193 FM (about 80%) matches had FM as first choice with the "top 5" alternates  that I mentioned - emerg, IM, psych, peds, anesthesia accounting for 146/264 of the alternate top choices.

[offmychestplease]

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[1D7]

The general interest levels rise in FM as students get closer to the match in M4.

In the earlier years students want to keep their options open and some of the competitive mindset from premed is still winding down. Once the reality of clinical years hit, lots of the idealized sunshine and roses are wiped away and many become dissuaded with spending 5+ years of their lives training in the hospital doing q4-q7 call (or worse). Additional factors include students realizing they have to consider their SO's life/family life, learning more about the job market reality for many specialists, watching the beatdowns certain programs still give their residents, and learning that the scope of FM is reasonably wide enough that they can be happy doing what they want.

[rmorelan]

2 hours ago, indefatigable said:

I don't think surgery is that high on the list of alternates first choice specialties for FM matches, at least in the first round.  According to the link I put in the post above, 929/1193 FM (about 80%) matches had FM as first choice with the "top 5" alternates  that I mentioned - emerg, IM, psych, peds, anesthesia accounting for 146/264 of the alternate top choices.

Oh I don't either - was mapping out worst case for that field in particular only because of all the fields surgeons going into family after going unmatched is consider to be the most "tragic" by many- there is more overlap in the jobs between IM, peds, emerg (which even potentially has of course a +1) and even psych than surgery particularly with some tailoring to your actual practice  

[indefatigable]

14 minutes ago, rmorelan said:

Oh I don't either - was mapping out worst case for that field in particular only because of all the fields surgeons going into family after going unmatched is consider to be the most "tragic" by many- there is more overlap in the jobs between IM, peds, emerg (which even potentially has of course a +1) and even psych than surgery particularly with some tailoring to your actual practice  

For sure, surgery is pretty different and there could be more initial disappointment - what's surprised me though is the number of surgery to FM transfers that I've seen including from ophtho and urology, probably because a lot of the factors that have been discussed above.  There's probably even more that switch away from specialties like ortho before CaRMS.

[rmorelan]

3 hours ago, offmychestplease said:

Just a first year, and not the largest sample size lol but it was funny how only 2/15 of people I spoke to said FM, when if we follow the trend by the end of medical school 7+/15 of that sample will ultimately go into FM. And thanks for adding the other points, that's what I thought as well but it's nice to get that confirmed. Maybe I'm wrong but I feel like in a group setting with a bunch of first year med students, saying you want FM is almost looked down upon as the "cool" or "right answer" is saying some intense speciality. This is frustrating as someone who is EXTREMELY interested in going into FM. 

completely not surprised ha - as a first year of course most don't really know the fields yet and a lot of different things can seem quite exciting. well they are exciting and as you put it "cool" - although after you have done your 1000s fill in the blank it may not be as much (but hopefully if you choose well still satisfying). 

Plus some may just be afraid that somehow saying they want family medicine is being uninspired about their choices ha. 

again in life it is probably best not to be punishing yourself for no reason. I like the fact that my job doesn't really seem like a job to me - I show up, there is a ton to do so time goes fast, and I am constantly interested. By some people standards that would be intense - particularly compared to other fields of radiology. However it works for me - I would like to think I found the right balance. Others need to do the same

 

 

Edited October 17, 2020 by rmorelan

[rmorelan]

4 minutes ago, indefatigable said:

For sure, surgery is pretty different and there could be more initial disappointment - what's surprised me though is the number of surgery to FM transfers that I've seen including from ophtho and urology, probably because a lot of the factors that have been discussed above.  There's probably even more that switch away from specialties like ortho before CaRMS.

I have seen that even in 5th year - that even they look ahead and realize that residency wasn't some hurtle you have to get over to reach green pastures - often over the hill is just more hill and while they could probably do it they just "had enough". 

Delayed gratification is very dangerous in medicine because you realize that really there isn't a clear end to it. Many staff work just as hard or harder than residents. The income only compensates for that so much - particularly when normal family matter crop up as well. You understand quickly why some professional really have very very little downtime. 

[rmorelan]

actually I should add the income can even be a real trap as well - once you ramp up to a particular roaster of patients, or develop your practice so you are the expert people go to in a particular area etc. it is often hard to ramp down if you want to. Those patients are now attached to you, people will need you to still be the available expert in area XYZ and so on.  If you realize you have taken on too much, you cannot quickly adjust - it takes a long time to adjust things - and if you aren't careful you can become dependent on the income to the point where you cannot change things financially either. That is not a good situation to be in and leads to burnout or worse.

One of the hardest transitions for many medical students in clerkship. Not just because it is a lot of work - they have been working hard already for a long time. It is the loss of control of their schedule. No matter what now you need to do the tasks assigned when they are assigned for as long as they are assigned. That is quite often new - to have your entire schedule locked in for the majority of your waking hours without any particular break really for the year (and then beyond). You have no choice in when to do something.  If you are tired, mentally out of it, or just going through something it doesn't matter - at 6am you are going to be rounding etc. The time you have to study is at a fixed point as well. Other jobs of course have this as well but they aren't working 80+ hours a week, and probably have more than 2-3 weeks vacation in most cases (and that vacation is always tied up usually with something else - like preparing for electives etc.)

Point is that continues and even becomes more concrete as staff for a variety of reasons. A lot of these intense fields sound fun until you actually do them and experience that loss of flexibility for a long period of time. 

Edited October 18, 2020 by rmorelan

[JohnGrisham]

There certainly were many in my medical school class that had FM as their number one choice right from the beginning.  I think around 40% of the class matched to FM, with a split of 30% FM only applications and 10%  back up with FM from applying to EM, OB, DERM etc.    The majority of people who match FM, had FM as their first choice, and certainly many only applied to FM. 

 

[medigeek]

21 hours ago, MasterDoc said:

It may be due to the fact that Family Med act as gatekeepers here and you need a referral to go see a specialists. Where else in the states as long as you have the funds you can go see any physician right away. 

One thing to note is that FM in Canada can also act as hospitalists and they generally have a much larger scope of practice. Hospitalists positions in the US are usually held by IM.

This is both true and false. FM in canada may be hospitalists more often in Canada than in USA, but they can be hospitalists in USA at most hospitals aside from the main large academic centers - and they're considered equal to IM in terms of competency at hospital medicine. Them being hospitalists less frequently in USA is due to personal choice largely. 

 

On 10/17/2020 at 1:04 AM, offmychestplease said:

I am wondering if this is a common trend among first year medical students in Canada. This is not a post to debate the pros/cons of FM/other fields. But, please share your experiences. A large number of classmates I have spoken to have expressed interest in going for a "speciality." A small minority of students have expressed interest in going into FM. I was wondering why the discrepancy and looked up Carms data which shows that in the last 5 years, 43-44% of CMGs ultimately went into FM. So is it safe to say that a lot of medical students go into medical school wanting to become a specialist but after finding out what it really takes (many more years of brutal training), the job prospects, while learning of the variety and possibilities in FM etc they back off and change their mind? These are the numbers:

2016: 44.0% of CMGs went into FM

2017: 43.2% of CMGs went into FM

2018: 43.1% of CMGs went into FM

2019: 43.6% of CMGs went into FM

2020: 42.7% of CMGs went into FM

I'm just trying to wrap my head around this as it would make more sense if way more students would have expressed initial interest in FM. Am I missing something? Did you find a large difference in the number of people in first year compared to later years (and after the match) who went into FM compared to those who initially expressed interest in it?

 

On a slightly different note, I was shocked to find out that only 8.6% of US MD grads went into FM. Any idea why literally 5x as many CMG grads go into FM here as opposed to American equivalents in the US??

https://www.aafp.org/students-residents/residency-program-directors/national-resident-matching-program-results.html

 

IM does a lot of primary care in USA and Peds does the bulk of primary care for kids. There's also more emphasis on use of specialists in USA (region dependent). FM also isn't in as many settings as they are in Canada (anesthesia, ED, etc.). That explains some of the differences in the difference in numbers. 

[Egg_McMuffin]

On 10/17/2020 at 3:01 PM, rmorelan said:

I have seen that even in 5th year - that even they look ahead and realize that residency wasn't some hurtle you have to get over to reach green pastures - often over the hill is just more hill and while they could probably do it they just "had enough". 

Delayed gratification is very dangerous in medicine because you realize that really there isn't a clear end to it. Many staff work just as hard or harder than residents. The income only compensates for that so much - particularly when normal family matter crop up as well. You understand quickly why some professional really have very very little downtime. 

I wish the school would spend more time on this point during our mandatory wellness workshops rather than the old "spend time to figure out what you're passionate in" type of advice. They haven't exactly portrayed residency and staff life as rainbows and unicorns, but any negative aspects mentioned hasn't really made people stop and really really think about what they might be getting into for the next 30-40 years of their career and the sustainability of it.

But then the more cynical part of me thinks no one wants the bright eyed MS1 and MS2s to realize they don't HAVE to volunteer their little free time towards research projects for academic physicians, sit on a bunch of committees, or staff friendship community projects if the pressure of matching to a competitive specialty is not quite there anymore. 

 

[rmorelan]

1 hour ago, Egg_McMuffin said:

I wish the school would spend more time on this point during our mandatory wellness workshops rather than the old "spend time to figure out what you're passionate in" type of advice. They haven't exactly portrayed residency and staff life as rainbows and unicorns, but any negative aspects mentioned hasn't really made people stop and really really think about what they might be getting into for the next 30-40 years of their career and the sustainability of it.

But then the more cynical part of me thinks no one wants the bright eyed MS1 and MS2s to realize they don't HAVE to volunteer their little free time towards research projects for academic physicians, sit on a bunch of committees, or staff friendship community projects if the pressure of matching to a competitive specialty is not quite there anymore. 

 

some of that is just hard I think to get across - I mean it is all abstract until you do it. Still we should do a better job. The problem with passion as a sole motivator is first off not every doctor will actually be passionate about about their field and may be passionate even about a field they didn't get into (which truly sucks) . Many just want to do a job that they enjoy and pays well but that isn't the sort of passion they are getting at with that line - they are describing the sort of enthusiasm where you would do it for the shear joy of it alone, endless, and be one of those radiant people inspiring those around you.  Relying on that for the field as a whole is a bit nuts in my opinion - those people are rare. Ideally there would be a list of reasons you make a particular career work - expecting people to always passionate about doing their 1000th on call surgery at 3am knowing you are rounding in 3 hours and have a few decades more to go is asking a lot  I don't see a lot of other professional fields using the passion argument anywhere near the degree medicine does. Worse it is often a code word to almost force people to doing things in an unfair fashion (as an example I love teaching, and would do it regardless - but to expect every doctor to do it for free is not a way to build a proper medical education system). 

We have tried to fix the stress previously in a few ways - getting rid of grades for instance - and have GREATLY improved both med student and residency life (not that we are done yet). Still haven't fixed the underlying problem that for competitive things no grades means you end us doing more of research and ECs as you have to do something to stand out (and will always have that problem). Also haven't fixed the problem that ultimately the end job for a lot of fields is ton of work, pain, stress and will involve big sacrifices even at baseline. We have to be at least open about that.