With a total of 145 Canadian medical student participants who were unsuccessful in securing a residency position after both iterations, this is the highest number of unmatched CMGs our nation has ever seen.

[doc_doc_doc]

https://www.cfms.org/news/2017/11/07/open-letter.html

[la marzocco]

1 hour ago, doc_doc_doc said:

https://www.cfms.org/news/2017/11/07/open-letter.html

"Finally, the CFMS strongly endorses a return of the ratio of Canadian medical student applicants to postgraduate entry positions to 1:1.2. In order to achieve this goal, we encourage the AFMC to work with provincial and federal governments to increase the number of residency positions available to CMGs."

Quick and easy way is to re-structure the matching process. I genuinely think the first iteration should just be for CMGs, and barring any exceptions (i.e., red flags based on MSPRs, interviews, CV reviews, etc.) that would deem the CMG unfit to practise, everyone qualified and competent CMG should be matched. I understand that the bottom one percentile of CMGs may not match, but that's more of a performance and competency issue. 

The second iteration then will be the residual positions for IMGs. 

 

[M148]

1 hour ago, qnzjlo said:

"Finally, the CFMS strongly endorses a return of the ratio of Canadian medical student applicants to postgraduate entry positions to 1:1.2. In order to achieve this goal, we encourage the AFMC to work with provincial and federal governments to increase the number of residency positions available to CMGs."

Quick and easy way is to re-structure the matching process. I genuinely think the first iteration should just be for CMGs, and barring any exceptions (i.e., red flags based on MSPRs, interviews, CV reviews, etc.) that would deem the CMG unfit to practise, everyone qualified and competent CMG should be matched. I understand that the bottom one percentile of CMGs may not match, but that's more of a performance and competency issue. 

The second iteration then will be the residual positions for IMGs. 

 

I'm strongly for cutting back IMG positions and giving them to CMGs. Make sure all the CMGs match and then fill the rest with AMGs and IMGs, in that order. 

[BoopityBoop]

I agree with all the sentiments above, but I'm also curious in the trends of ranking amongst CaRMs applicants over the years

Are there proportionally more applicants wanting more competitive specialties or more applicants wanting to match to large cities (Vancouver, Toronto, Montreal)?

It would be interesting to see how CaRMs will need to readjust to the interests/values of different generations in years to comes.

Does anyone know if this increase in unmatches are a cyclical event? 

[JohnGrisham]

OR we can reduce some of the CMG seats.

While cutting out IMGs would also work, it would be at the loss of the ROS contracts. While its a band-aid and doesn't necessarily help long-term retention, its still better than nothing.
 

[shady]

Grads don’t have a right to match. They need to earn it. I dont believe we should hand out residency positions to people who are having trouble matching in the current already lopsided system, with more positions than grads

 

1:1.2 ratio is way to low. 1:1.01 is more reasonable

[JohnGrisham]

3 minutes ago, shady said:

Grads don’t have a right to match. They need to earn it. I dont believe we should hand out residency positions to people who are having trouble matching in the current already lopsided system, with more positions than grads

 

1:1.2 ratio is way to low. 1:1.01 is more reasonable

Usually we put /S to indicate sarcasm on the internet, so uninitiated that read your post dont think otherwise

[shady]

5 minutes ago, JohnGrisham said:

Usually we put /S to indicate sarcasm on the internet, so uninitiated that read your post dont think otherwise

Its a medical student echochamber so of course this would be an unpopular opinion

 

The reality of the matter, however, is we [doctors] have created and structured a system that caters to our every need without regard to effects on society. We even misconstrue things that are inconveniences to us as harms to society to get the public to buy into it

 

In this prticular case, the system could really use a tool to weed out the lower few % of medical students. If people are having trouble matching in a system of more spots than applicants, then they need to work on themselves before trying to change the system. Otherwise, we would be doing away with the only point of real competition in medical education and allowing the mediocre to coast effortlessley at a cost borne by Canadian patients in the form of substandard care

[la marzocco]

Which is why I said.. that CMGs should still be judged based on merit so that they "earn a spot" but it's just to prevent the 125 unintended unmatched grads. I highly doubt all 125 CMGs that went unmatched did not "merit" a position. I would argue most of the 125 CMGs earned it, but they fell victim to the algorithm and the structure of the iterations. Even, for sake of concession, you argue 50% of the CMGs that went unmatched are in fact incompetent, fine. Then the remaining 50% are unintended consequences. We need to close this gap.

I agree with @shady's point about prevention of substandard care, but I don't think that is the issue. I think the fact is that the most of the unmatched doctors are still equally qualified barring the few that I had mentioned above ^.

Paring back Canadian medical school enrolment is an option.. we are seeing it in Quebec already - each Quebec med school is paring back 10 seats for the coming cycle and potentially for 3 more cycles. That will reduce 120 of CMGs over the course of three years.

[ellorie]

While the CFMS push for increasing CMG spots is getting the most attention here - I actually think that the other measures they suggested are super reasonable and important.  Standardizing and implementing supports for unmatched students is a great idea, and particularly standardizing the "extended clerkship" concept.

I also think that the distribution of spots continues to be an issue.  If residency spots are added, they should be in those specialties where additional physicians are needed (FM [especially rural FM], psychiatry, etc), and I'd say many unmatched students would not be willing to practice those specialties.  A large chunk of those 145 did not even go into the second round for whatever reason, likely due to unwillingness to end up in any of the available specialties.  We can open up more spots, but if the unmatched folks are only willing to accept, for example, surgical specialties, and that's why they've gone unmatched, it's not going to solve anything.  Many of the spots that IMGs end up in are spots that CMGs don't want, including spots that require ROS.

I think there needs to be a major re-allocation of residency spots to align supply with demand for physicians in those areas, and to prevent people from finishing specialties and finding that there are no jobs for them.

[shady]

45 minutes ago, ellorie said:

While the CFMS push for increasing CMG spots is getting the most attention here - I actually think that the other measures they suggested are super reasonable and important.  Standardizing and implementing supports for unmatched students is a great idea, and particularly standardizing the "extended clerkship" concept.

I also think that the distribution of spots continues to be an issue.  If residency spots are added, they should be in those specialties where additional physicians are needed (FM [especially rural FM], psychiatry, etc), and I'd say many unmatched students would not be willing to practice those specialties.  A large chunk of those 145 did not even go into the second round for whatever reason, likely due to unwillingness to end up in any of the available specialties.  We can open up more spots, but if the unmatched folks are only willing to accept, for example, surgical specialties, and that's why they've gone unmatched, it's not going to solve anything.  Many of the spots that IMGs end up in are spots that CMGs don't want, including spots that require ROS.

I think there needs to be a major re-allocation of residency spots to align supply with demand for physicians in those areas, and to prevent people from finishing specialties and finding that there are no jobs for them.

You're hitting the nail on the head. This is excellent

[GrouchoMarx]

Any specialties that require fellowships to get jobs in cities with major airports should have spots cut. That includes pathology.

 

Derm OTOH needs spots added.

[GrouchoMarx]

1 hour ago, ellorie said:

While the CFMS push for increasing CMG spots is getting the most attention here - I actually think that the other measures they suggested are super reasonable and important.  Standardizing and implementing supports for unmatched students is a great idea, and particularly standardizing the "extended clerkship" concept.

I also think that the distribution of spots continues to be an issue.  If residency spots are added, they should be in those specialties where additional physicians are needed (FM [especially rural FM], psychiatry, etc), and I'd say many unmatched students would not be willing to practice those specialties.  A large chunk of those 145 did not even go into the second round for whatever reason, likely due to unwillingness to end up in any of the available specialties.  We can open up more spots, but if the unmatched folks are only willing to accept, for example, surgical specialties, and that's why they've gone unmatched, it's not going to solve anything.  Many of the spots that IMGs end up in are spots that CMGs don't want, including spots that require ROS.

I think there needs to be a major re-allocation of residency spots to align supply with demand for physicians in those areas, and to prevent people from finishing specialties and finding that there are no jobs for them.

The second round spots are largely poor options if youre set on particular specialties. FM is given a lot of undeserved ridicule and is treated quite poorly nationwide, and other 2nd round mainstays psych and path are so unique that i would not expect most unmatched students to go into those fields. IMO the issue is a lack of flexibility. just because you couldnt get into a specialty the first time should not mean youre barred from it for life.

[JohnGrisham]

2 hours ago, shady said:

Its a medical student echochamber so of course this would be an unpopular opinion

 

The reality of the matter, however, is we [doctors] have created and structured a system that caters to our every need without regard to effects on society. We even misconstrue things that are inconveniences to us as harms to society to get the public to buy into it

 

In this prticular case, the system could really use a tool to weed out the lower few % of medical students. If people are having trouble matching in a system of more spots than applicants, then they need to work on themselves before trying to change the system. Otherwise, we would be doing away with the only point of real competition in medical education and allowing the mediocre to coast effortlessley at a cost borne by Canadian patients in the form of substandard care

The problem is there is only marginal # spots more than students for english speaking Canada.  And your statement misses the point of varying options of specialties, not a once common end point.  So a bit more nuanced.

But i dont disagree otherwise. 

[indefatigable]

.

 

[JohnGrisham]

I commend quebec for cutting back seats - hopefully rest of Canada takes that approach, if they arent going to fix the residency ratio via shuffling the residency positions. 

Ironically, quebec cutting down its seat while good, has less of an effect since they always have far more leftover seats than english Canada.

[indefatigable]

1 hour ago, JohnGrisham said:

I commend quebec for cutting back seats - hopefully rest of Canada takes that approach, if they arent going to fix the residency ratio via shuffling the residency positions. 

Ironically, quebec cutting down its seat while good, has less of an effect since they always have far more leftover seats than english Canada.

Yes - they didn't cut down only for residency positions but also for the job market later from what I understand.  Too many fully trained physicians were having trouble getting permanent spots - so the quebec identity cuts a little both ways (more residency positions but sometimes people more reluctant to move outside of Quebec).  

[shikimate]

I know the CFMS stands for Canadian medical students, but if we make all MS2 write Step 1 like the Carib does I bet a lot of this problem would be solved.

[JohnGrisham]

2 hours ago, shikimate said:

I know the CFMS stands for Canadian medical students, but if we make all MS2 write Step 1 like the Carib does I bet a lot of this problem would be solved.

Not really. Visa's are a limiting factor for US training. I think it would be more appropriate to have those who go unmatched in March strongly encouraged to write steps at that time instead and given the time off from unnecessary duties, if any, post carms to prepare. That way they can apply to NRMP in parallel with CaRMS the following year. 

Having everyone write it at end MS2 would be pointless since the vast majority will match just fine in Canada. 

 

[distressedpremed]

I really don't understand why we can't have the GP licensure back. 

I really feel for my unmatched colleagues - as I've mentioned in the past, as I approached fourth year I really felt like medical school sometimes was less about being a adequate/competent physician and that we were pressured to "match" as well as possible. The MD degree is very limited in ability or scope if you don't match. 

So if the MD degree is, by some means useful in preparing one for clinical medicine, then why can't unmatched candidates enter a rotating year where they still have the MD and still sign orders? And then after that probationary period of one year of general medicine (spatterings of different specialties), they can write the LMCCII. After LMCII they can technically do extenderships or moonlight in some capacity? 

Because that is literally what PGY-1 entering PGY-2 is for a lot of residents, regardless of specialty. Not a lot of PGY-1 is dedicated to the specialty that you matched to anyway - a lot of my time is off-service. The real learning starts near PGY-2 for my specialty and a lot of other specialties. 

But yet if I finish PGY-1 and then be able to write LMCCII, I can technically do extenderships or moonlight even outside of my specialty. I don't think that me, just because I matched to a program and finished a generalized year, is something unique to the fact that I matched...I think I only have this opportunity because I matched. I think that any of my colleagues who were unmatched from a canadian med school could have done this year as well (or better) than I have. 

Which begs the question - why do we have to put so much value in the match? They can be undeclared physicians who can practice some sort of general medicine in a focused or limited setting while waiting to re-enter the match...oh wait....that sounds like being a general practitioner, and that's vehemently opposed by certain physician groups. 

Like I'm really confused, and again, I feel for people who don't match. I felt like it was a big random draw at the end and I was incredibly lucky. I think with so much at stake the system should be better than just acting like a seive based on luck. 

[goleafsgochris]

24 minutes ago, distressedpremed said:

I really don't understand why we can't have the GP licensure back. 

I really feel for my unmatched colleagues - as I've mentioned in the past, as I approached fourth year I really felt like medical school sometimes was less about being a adequate/competent physician and that we were pressured to "match" as well as possible. The MD degree is very limited in ability or scope if you don't match. 

So if the MD degree is, by some means useful in preparing one for clinical medicine, then why can't unmatched candidates enter a rotating year where they still have the MD and still sign orders? And then after that probationary period of one year of general medicine (spatterings of different specialties), they can write the LMCCII. After LMCII they can technically do extenderships or moonlight in some capacity? 

Because that is literally what PGY-1 entering PGY-2 is for a lot of residents, regardless of specialty. Not a lot of PGY-1 is dedicated to the specialty that you matched to anyway - a lot of my time is off-service. The real learning starts near PGY-2 for my specialty and a lot of other specialties. 

But yet if I finish PGY-1 and then be able to write LMCCII, I can technically do extenderships or moonlight even outside of my specialty. I don't think that me, just because I matched to a program and finished a generalized year, is something unique to the fact that I matched...I think I only have this opportunity because I matched. I think that any of my colleagues who were unmatched from a canadian med school could have done this year as well (or better) than I have. 

Which begs the question - why do we have to put so much value in the match? They can be undeclared physicians who can practice some sort of general medicine in a focused or limited setting while waiting to re-enter the match...oh wait....that sounds like being a general practitioner, and that's vehemently opposed by certain physician groups. 

Like I'm really confused, and again, I feel for people who don't match. I felt like it was a big random draw at the end and I was incredibly lucky. I think with so much at stake the system should be better than just acting like a seive based on luck. 

This bothered me so much as a med student, because its such an easy solution.

I think it should be set up like the end of general internal medicine residency programs.  They have a match to apply to subspecialties across Canada, but if they don't match (or choose not to), their home school lets them do a year of general IM.  You could do the same thing with med schools.  Would take away all the stress.

I already understand WHY this isn't the case--because family medicine was declared its own "specialty" they wont allow anyone to practice without completing that residency.  This is a pretty shit reason.  Especially since most family med programs don't seem to offer a lot of additional knowledge to their residents, aside from the experience of being in more GP clinics which I guess is practically useful.  They could easily reverse this decision and go back to the internship year if someone had the balls to stand up to the fam med people who might get offended.

Because the truth is this: even after carms, you can STILL GET FUCKED AGAIN because you don't have the general licence!  When I was finishing residency, if I had failed the exams, I would essentially have no way to earn income for a year until I write the exam again.  It caused a huge amount of stress and for no real reason--by that point I could work at a walk in clinic laughably easily

[JohnGrisham]

"I already understand WHY this isn't the case--because family medicine was declared its own "specialty" they wont allow anyone to practice without completing that residency.  This is a pretty shit reason.  Especially since most family med programs don't seem to offer a lot of additional knowledge to their residents, aside from the experience of being in more GP clinics which I guess is practically useful."

So...in your opinion what is it that you think FM residents do? Or am i misreading your statement that the FM residency "doesnt seem to offer a lot of additional knowledge" compared to post M4 knowledge? 

In theory, those programs should be training residents with far more depth and capability than the limited services offered by walk-in clinics.  

As for someone who fails the IM royal college boards, why should they be able to get a license to walk-in clinics in the mean time...when someone who failed their surgery boards likely wouldnt be allowed the same privelege?(I think we can agree someone whos been doing some other specialized focus for 4-5 years, or even most other fields is probably not equipped to practice proper FM). A year of no income sucks, but its not going to make or break anyone in the long-term.

Alternatively the option is to simply just add more FM training spots, instead of this unstandardized semblence of GP-training of the past. 



 

[ralk]

2 hours ago, distressedpremed said:

I really don't understand why we can't have the GP licensure back. 

I really feel for my unmatched colleagues - as I've mentioned in the past, as I approached fourth year I really felt like medical school sometimes was less about being a adequate/competent physician and that we were pressured to "match" as well as possible. The MD degree is very limited in ability or scope if you don't match. 

So if the MD degree is, by some means useful in preparing one for clinical medicine, then why can't unmatched candidates enter a rotating year where they still have the MD and still sign orders? And then after that probationary period of one year of general medicine (spatterings of different specialties), they can write the LMCCII. After LMCII they can technically do extenderships or moonlight in some capacity? 

Because that is literally what PGY-1 entering PGY-2 is for a lot of residents, regardless of specialty. Not a lot of PGY-1 is dedicated to the specialty that you matched to anyway - a lot of my time is off-service. The real learning starts near PGY-2 for my specialty and a lot of other specialties. 

But yet if I finish PGY-1 and then be able to write LMCCII, I can technically do extenderships or moonlight even outside of my specialty. I don't think that me, just because I matched to a program and finished a generalized year, is something unique to the fact that I matched...I think I only have this opportunity because I matched. I think that any of my colleagues who were unmatched from a canadian med school could have done this year as well (or better) than I have. 

Which begs the question - why do we have to put so much value in the match? They can be undeclared physicians who can practice some sort of general medicine in a focused or limited setting while waiting to re-enter the match...oh wait....that sounds like being a general practitioner, and that's vehemently opposed by certain physician groups. 

Like I'm really confused, and again, I feel for people who don't match. I felt like it was a big random draw at the end and I was incredibly lucky. I think with so much at stake the system should be better than just acting like a seive based on luck. 

Reintroducing GP liscensure isn't such a simple solution here...

For one, a rotating internship still requires post-graduate training positions, with funding and sufficient learning opportunities, the lack of which is the main problem in the first place. It's one less year than an FM residency spot, but it's not like there's a rush to open up more FM spots either. GP liscensure has the exact same bottleneck as the current system - too few post-graduate residency spots.

Second, current PGY-1 years are far removed from prior rotating internships. Sure, there's a lot of off-service rotations, but aside from FM, it's hard to call it a generalist year these days. The only commonalities are a month in the CTU and usually a month in the ER - no one's doing runs through outpatient FM clinics, or nursing homes, or walk-in clinics - which is what GPs would be doing. Almost no residents moonlight without certification these days, even if it is a theoretical possibility.

The best argument I see for a rotating internship leading towards a GP certification is that FM training leaves a lot to be desired, so a GP wouldn't be too far off current GPs in terms of standards of practice and ability. But that just means making a bad situation worse - FM docs are often great once they gain some experience, but there's such a wide range of FM quality that many mediocre or (occasionally) straight-up bad physicians make it into practice. Reestablishing the GP route means there's even more variability in practitioners and fewer safeguards, while adding complexities to the system that make it even harder to push for higher standards.

I think there are easier and more targeted solutions here. First, flip half the current IMG spots across the board into CMG spots. Heck, if that gets done for FM spots alone it would substantially reduce the number of unmatched current-year CMG grads after the second round. Second, let unmatched MDs work in the same role as PAs while they go through the match again. PAs are individuals with no independent practice rights working under the direction of a full-certified physician - basically what a resident is supposed to be minus the educational component. Means we don't have to lower safety or training standards from current practice and unmatched MDs get opportunities to work that pay better than residency does while gaining relevant experience for future matches.

[goleafsgochris]

14 minutes ago, JohnGrisham said:

"I already understand WHY this isn't the case--because family medicine was declared its own "specialty" they wont allow anyone to practice without completing that residency.  This is a pretty shit reason.  Especially since most family med programs don't seem to offer a lot of additional knowledge to their residents, aside from the experience of being in more GP clinics which I guess is practically useful."

So...in your opinion what is it that you think FM residents do? Or am i misreading your statement that the FM residency "doesnt seem to offer a lot of additional knowledge" compared to post M4 knowledge? 

In theory, those programs should be training residents with far more depth and capability than the limited services offered by walk-in clinics.  

As for someone who fails the IM royal college boards, why should they be able to get a license to walk-in clinics in the mean time...when someone who failed their surgery boards likely wouldnt be allowed the same privelege?(I think we can agree someone whos been doing some other specialized focus for 4-5 years, or even most other fields is probably not equipped to practice proper FM). A year of no income sucks, but its not going to make or break anyone in the long-term.

Alternatively the option is to simply just add more FM training spots, instead of this unstandardized semblence of GP-training of the past. 



 

Ah sorry, didn't mean it like that.

Fam med residents learn WAY more than an M4.  What I mean is that from my interactions with them (and their opinions, at least in Toronto), they don't learn that much more than they would have in a general internship year, aside from some soft-ish skills gained from being in the fam med clinics.

Also, yeah I did mean that it would apply to surgery residents also.  I think that ANYONE who passes the LMCC-2 should be able to do walk in clinics, my point being that any resident should be qualified to do that if they fail the boards, by the fact that they passed the LMCC2 (which was initially the point of that exam).  

 

[JohnGrisham]

3 minutes ago, goleafsgochris said:

Ah sorry, didn't mean it like that.

Fam med residents learn WAY more than an M4.  What I mean is that from my interactions with them (and their opinions, at least in Toronto), they don't learn that much more than they would have in a general internship year, aside from some soft-ish skills gained from being in the fam med clinics.

Also, yeah I did mean that it would apply to surgery residents also.  I think that ANYONE who passes the LMCC-2 should be able to do walk in clinics, my point being that any resident should be qualified to do that if they fail the boards, by the fact that they passed the LMCC2 (which was initially the point of that exam).  

 

I guess the other counter-argument is, as ralk already mentioned is funding. Why do this roundabout way and huge overhaul, when we can simply flip some IMG training spots?  If adding more FM spots in itself was a solution, they'd already do that - but funding is an issue and very innefficiently not streamlined.

The other is, if people are in some form or another gauranteed a rotating internship...then you'll see a huge increase in competition for the specialties anyways - because if you know youre going to get a GP spot, then you sure better bet a large portion of those currently going for a FM spot will work towards a 5 year program instead.  So, unless more funding comes and everyone leftover can be accomodated with a GP spot.... then it wouldnt make a difference.  If this WAS the case - then why even bother doing all that, when you can just keep the current system and add more FM spots. 

Circular reference of sorts, leading back to funding.  Or avoid the funding issue all together, and flip some IMG spots. But then the cash cow of MCCEE and Nac OSCEs might be affected if IMGs realize there is even LESS opportunity for canadian training.....