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Robert Chu--Unmatched Doctor Commits Suicide


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As a McMaster student, I would like to comment with my two cents on the kind of support McMaster provides to students and what we are currently doing to make things better. I'm not sure what kind of support is available at other schools, but it would be good to know so we can make improvements on our current system.

1) We have an extension to clerkship program where students who did not match in the first and second iteration can complete an additional 16 weeks of clinical electives in order to strength their reference letters and make clinical connections for Carms. You have to diversify these electives - you cannot do 16 weeks in one speciality or location.

2) We have a minimum of 3 career counselling sessions for all students applying for Carms. The first one is to explore what field the students are interested in and get them thinking more about why they would want to pursue a career in that speciality. We discuss references, electives, and any other concerns the student may have. The second is to go over the CV and statements of interest and other parts of the actual application. And then third is for interview practice.

3) Students who go unmatched have access to all career and personal counselling services.

Currently, our student council is working with administration to conduct a thorough mental health needs assessment to identify points of weakness and improvement within our support systems. I imagine once this is complete, we will implement some of the recommended changes for future students.

I don't know Dr. Chu's specific scenario or what advice career/personal counselling gave him. Although the Carms system is definitely a stressor and needs improvement, we must remember that the decision to take one's own life is rarely due to a singular reason. The culture of medicine can also be extremely detrimental to one's physical and mental health and needs improvements of its own.

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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 don't really think most people were disparaging IMGs or bashing diversity in Canada. Lots of IMGs and CSAs come to the Canadian system with the knowledge and abilities necessary to be excellent physicians. I think the point made about protecting the CMG's interests over others is valid not because CMGs are "better" than anyone else but because the Canadian taxpayers have already made a HUGE investment by virtue of them being CMGs. The average taxpayer investment to educate a single medical student is incredibly substantial (estimates range from 100k-250k+ depending on what province you're in and how much funding your school gets). To spend that kind of public money to provide an education to a CMG and then have that MD degree be essentially worthless because of a lack of residency spots is ludicrous. I think IMGs bring a lot to the table and there should be a way for qualified IMGs to enter the Canadian system for practice... but the system also has a fiduciary duty to the taxpayers of this country to ensure that the investment made in medical students is something that, in the end, benefits the taxpayers that made the investment. An MD who cannot practice benefits nobody.

Now, Canadian students who choose to go to another country to do their medical education because it is easier to gain admissions to those institutions do so knowing full well that the route to come back is difficult and becoming more difficult each day. It is a calculated risk. Either way, it is obvious the system cannot support the number of people who would like to practice in it. There will always be a limiting step in medical education. Ideally that rate limiting step should be at the admission to medical school level so we don't have students completing years of schooling and costing thousands of taxpayer dollars only to be unable to practice because they cannot get a residency. For-profit institutions in other countries have unfortunately found a way to capitalize on student desperation and offer what looks like a way to circumvent the limiting step of admissions. I know many Canadian students who study abroad (including a couple of my friends) choose to do so because medicine is their dream and they are unable to get in to a Canadian institution (be that for reasons of luck or GPA or interview ability). I feel for them but at the end of the day the job of the Canadian medical system has nothing to do with any one individual's career aspirations or dreams... the job of the Canadian medical system is to provide quality, sustainable healthcare to the Canadian population. A big part of fulfilling this obligation includes ensuring that the investment made in medical education pays off for the taxpayer. 

Residency matching is going to be a huge challenge in the coming years. As far as what can be done... a lot of people have already posted and discussed some potential ideas on how this could be addressed. Given the number of stakeholders in the game, I suspect it will be a very difficult problem to solve, but it is a worthwhile discussion to have. At the end of the day the medical system has a finite capacity for practicing physicians. Any possible solutions need to work within the confines of this capacity issue. I suspect the solution lies in a combination of the below (many of which have been mined from other responses in this thread):

1. Add more residency spaces - not entirely feasible due to the need to balance residency positions with jobs at the end of residency. Potentially there could be something to say for removing the french-only residency positions from the calculation of available residency positions since not all students can fill these (not eliminating the spots, just calculating the numbers differently).
2. Reduce the number of medical school spaces - not ideal, but if residency positions continue to be cut then medical school positions should also be decreased by the same number. 
3. Limit entry of IMGs/CSAs into the system, but this is done at the expense of diversity in the case of IMGs. I personally think this kind of approach throws the baby out with the bath water but it is also an elephant in the room that needs to be acknowledged. 
4. Find a way to entice more students into the French-only residency positions - this is where a majority of the "empty" residencies exist each year but many students do not meet the language requirements. Ideally there would be a way to entice those who do meet the language requirements to preferentially fill these positions.
5. Increase the obligation of medical schools to support and assist unmatched students in getting a residency - ensure all medical schools have a plan in place on how to deal with un-matched students that goes beyond "get them into a grad program and hope they figure it out next match"
6. Have a general rotation year available to students who do not match - similar to the "extended clerkship" offered by some schools. 
7. Restrict all residency positions to CMGs until CMGs have all matched, then open remaining positions to IMGs/CSAs - again, this is at the expense of diversity and I question if this would also prevent programs from being able to recruit the most qualified/best candidates for their residency positions. 
8. Have CaRMs provide more information to students/home schools about WHY the did not match. Whether that is interview scores or just having each school choose from a drop-down list of options about why they chose not to interview/rank a student etc. It is hard to improve for the next match if you don't know why the first match did not go well for you. I suspect privacy legislation would make this difficult, but honestly I think good quality feedback would go a long way in solving this problem. As it stands now schools try to give you their best guess if you don't match, but nobody really knows. It's like trying to shoot at targets while wearing a blindfold - your school can tell you in board terms where the targets are, but it's really tough for them to help you aim when they can't see down the same sight line. 


Did I miss anything when rounding up the ideas in this thread? I find system discussions like this really interesting - I'd love to hear more of the unique ideas that people have about how to begin solving the residency matching problems. 

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23 hours ago, LittleDaisy said:

II 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. 

 

Of course it requires hard work. But the thing is there are many many people who don't get accepted who are basically indistinguishable from any matriculating CMGs 95+% of the time. I would say the difference between those who were accepted and the next 10-20% of applicants IS luck.

In other words...hard work is necessary but not sufficient to get into med school.

I'm currently a CMG, who was previously a CSA for 2 years in Ireland and I can tell you the difference between most of my CSA classmates and my CMG ones is virtually nil.

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22 hours ago, Intrepid86 said:

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.

Spot on. Similarly, not every CSA comes from a high SES background. The loans I've seen some of my CSA friends take out were insane (some could only go abroad because they had divorced parents who could therefore provide two independently co-signed loans)

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26 minutes ago, daftjustice said:

Of course it requires hard work. But the thing is there are many many people who don't get accepted who are basically indistinguishable from any matriculating CMGs 95+% of the time. I would say the difference between those who were accepted and the next 10-20% of applicants IS luck.

In other words...hard work is necessary but not sufficient to get into med school.

I'm currently a CMG, who was previously a CSA for 2 years in Ireland and I can tell you the difference between most of my CSA classmates and my CMG ones is virtually nil.

I'd venture to say that at some schools its more like 40-50% of the next in line. Really most people who make it to interview, and even many that dont...would be practically no different from the perspective of ultimate patient care.

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4 hours ago, MSWschnoodle said:

n the confines of this capacity issue. I suspect the solution lies in a combination of the below (many of which have been mined from other responses in this thread):

1. Add more residency spaces - not entirely feasible due to the need to balance residency positions with jobs at the end of residency. Potentially there could be something to say for removing the french-only residency positions from the calculation of available residency positions since not all students can fill these (not eliminating the spots, just calculating the numbers differently).
2. Reduce the number of medical school spaces - not ideal, but if residency positions continue to be cut then medical school positions should also be decreased by the same number. 
3. Limit entry of IMGs/CSAs into the system, but this is done at the expense of diversity in the case of IMGs. I personally think this kind of approach throws the baby out with the bath water but it is also an elephant in the room that needs to be acknowledged. 
4. Find a way to entice more students into the French-only residency positions - this is where a majority of the "empty" residencies exist each year but many students do not meet the language requirements. Ideally there would be a way to entice those who do meet the language requirements to preferentially fill these positions.
5. Increase the obligation of medical schools to support and assist unmatched students in getting a residency - ensure all medical schools have a plan in place on how to deal with un-matched students that goes beyond "get them into a grad program and hope they figure it out next match"
6. Have a general rotation year available to students who do not match - similar to the "extended clerkship" offered by some schools. 
7. Restrict all residency positions to CMGs until CMGs have all matched, then open remaining positions to IMGs/CSAs - again, this is at the expense of diversity and I question if this would also prevent programs from being able to recruit the most qualified/best candidates for their residency positions. 
8. Have CaRMs provide more information to students/home schools about WHY the did not match. Whether that is interview scores or just having each school choose from a drop-down list of options about why they chose not to interview/rank a student etc. It is hard to improve for the next match if you don't know why the first match did not go well for you. I suspect privacy legislation would make this difficult, but honestly I think good quality feedback would go a long way in solving this problem. As it stands now schools try to give you their best guess if you don't match, but nobody really knows. It's like trying to shoot at targets while wearing a blindfold - your school can tell you in board terms where the targets are, but it's really tough for them to help you aim when they can't see down the same sight line. 


Did I miss anything when rounding up the ideas in this thread? I find system discussions like this really interesting - I'd love to hear more of the unique ideas that people have about how to begin solving the residency matching problems. 

I think this is a nice summary of the main ideas.  

- 1 and 2 deal with demand/supply of medical students/residents.  

- 3 and 7 consider the IMG/CSA issue.

- 4 deals with Quebec (and 1).

- 5 and 6 look at options after not matching

- 8 looks at more transparency for the matching process.  

I like 8.  I think that this could be really helpful for unmatched students, a bit like faculties can give feedback on applications or interview.  

With respect to Quebec (1&4), it's really its own world and the student federation does meet & put direct pressure on the health ministry directly.  Internally, supply of medical students is possibly going to decreased.  A number of the open positions are in remote regions which are less appealing than training closer to family and friends for many Quebecers, not to mention changes to FM practice rules.  I'd also say that adjustments for non-francophones would be particularly difficult and writing the MLEs to end up somewhere in the US would probably be easier for many.  I agree that removing the Quebec spots from calculations would give a more accurate picture.

With respect to 3&7, I worry that the problems with the PhD system will be recreated.  It's an open secret that Canadian PhDs in a lot of disciplines are not considered as 'good' as many US or internationally trained PhDs, so basically in a lot of cases, Canadian PhDs aren't in demand domestically but not really outside of Canada either.  In practice, ambitious prospective academics circumvent this by going to american schools for their PhD to get a faculty job back in Canada.  I wouldn't want to see the parallel of this type of thinking in medicine, where the public and individual costs for MD training  and economic barriers for going abroad are much higher.  

I think 5 is one that should be universally adopted by all faculties, as well as the extended clerkship in 6.  The general rotation year seems controversial.  

 

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On 6/19/2017 at 5:30 AM, ralk said:

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.

But rotating internships weren't all alike - there were some that medicine-focused, others very generalist, others aimed to surgery. Not everyone completed an intern year either, and instead went directly into a Royal College specialty residency. Others did the year, got a general license, and practised for a while before doing something else. The point is that there were more options, more ability to train and work as a generalist while later pursuing specialty options. The advent of CaRMS eliminated that flexibility, and despite talk of the algorithm "favouring" applicants, previously you could apply anywhere and entertain offers simultaneously. If you didn't get the RC program or had second thoughts, there was always the "backup" of working as a GP. 

Otherwise I request that you provide evidence that the two-year CCFP program is "safer" than the old model. I don't think medicine is actually "far more complex"; it has always been so. We just have more fancy imaging tests and investigations and drugs to play with. But for family medicine these aren't always altogether relevant. I'll say as someone now on the other side of the RC exams, there is always so much more to know, and some of that only comes once you get into practice. You can always make safe decisions when you know what you don't know. 

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Just now, A-Stark said:

But rotating internships weren't all alike - there were some that medicine-focused, others very generalist, others aimed to surgery. Not everyone completed an intern year either, and instead went directly into a Royal College specialty residency. Others did the year, got a general license, and practised for a while before doing something else. The point is that there were more options, more ability to train and work as a generalist while later pursuing specialty options. The advent of CaRMS eliminated that flexibility, and despite talk of the algorithm "favouring" applicants, previously you could apply anywhere and entertain offers simultaneously. If you didn't get the RC program or had second thoughts, there was always the "backup" of working as a GP. 

Otherwise I request that you provide evidence that the two-year CCFP program is "safer" than the old model. I don't think medicine is actually "far more complex"; it has always been so. We just have more fancy imaging tests and investigations and drugs to play with. But for family medicine these aren't always altogether relevant. I'll say as someone now on the other side of the RC exams, there is always so much more to know, and some of that only comes once you get into practice. You can always make safe decisions when you know what you don't know. 

If we're having highly variable rotating internships, then we're just back to square 1 when it comes to residency matching, just a year later. Now, instead of a 4th year student setting themselves up to do radiology and nothing else, we'll have an intern setting themselves up to do radiology and not much else. You can't have it both ways - if the rotating internship is there to provide a back-up that allows for generalist practice, it can't simultaneously allow the flexibility to apply for specialist residency programs, not when programs care so much about candidates signalling their desires to go into a particular field and their exposure to that field. Such a system gives the illusion of options, without actually opening up new pathways. If residency programs were far easier to access, as they were in the early 1990's, then perhaps those options would really open up, not just on paper, but in actuality. However, if residency programs were far easier to access, we wouldn't be having this discussion in the first place.

The only way a rotating internship that isn't static in its rotations allows for both further specialty applications and a way out if a specialty position isn't obtained is if we're letting people practice as GPs with even less exposure to the primary care setting they'd be working in than the situation I was originally criticizing with GPs having static, undifferentiated training.

There's no evidence either way on whether the current two-year CCFP program is safer than the old model, but that runs both ways. Neither of us can prove a hypothetical. However, what you're suggesting is that current FP training could not only be cut in half, but be made less focused, and there would be little to no negative consequences for patients. We're clearly missing a huge opportunity to save costs if that's true.

I have to say though, I think you hit the nail on the head as to why I think having GPs with only a year of unfocused training are potentially hazardous to patients - they don't know what they don't know. I agree, there's always more to know, but I'm not concerned about a GP coming across a disease they've never seen before and being stumped. I'm concerned about a physician treating a patient and thinking they did a good job because no one's around to tell them otherwise. Residency is the last time physicians are truly supervised, where actions that seem like they work, but actually don't, can be corrected. Physicians lack feedback mechanisms, especially those in independent primary care practices. A GP who has spent minimal time in an actual primary care clinic may have all the medical knowledge they need, or the ability to obtain it, but won't have the practical experience necessary to tell an effective approach with a patient from an ineffective one.

The parallel I draw is to my own training in healthcare prior to medical school. It required a fraction of the knowledge medicine did and the job required a much smaller set of tasks to be performed. I can say pretty confidently that I had good mastery of my field's required knowledge before gaining significant clinical experience. Yet, to do that job, I still had a full year of clinical training which was far more applied and practical than anything I've gone through in medical school. Even after being fully certified, I was supervised by not only my more experienced co-workers, but the physicians I was working with, providing ample checks on my ability to do my job correctly. If I didn't know what I didn't know, they'd be able to catch me. When you say that GPs would be fine to practice after only one year of post-graduate training, what you're telling me that where I am right now, as a fresh MD grad, is only a year away from being a fully independent physician. Yet, it took me that long to train to do a less complicated job (though not a necessarily easier one), when I was starting from a much stronger position of knowledge relatively speaking, and which still required ample oversight to do safely. And you're telling me that'll all somehow get done with less focused training than I'm even going to get as an FM resident, which is itself less focused than what I got in my previous career. That doesn't add up to me. I've been a good student and I've worked hard to make myself as capable an incoming resident as I can be. At worst, I think I'm an average graduating student, but coming from someone who's been an independent healthcare practitioner before, I'm more than a year away from being able to practice medicine independently in a safe manner.

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On 6/20/2017 at 3:50 PM, ralk said:

There's no evidence either way on whether the current two-year CCFP program is safer than the old model, but that runs both ways. Neither of us can prove a hypothetical. However, what you're suggesting is that current FP training could not only be cut in half, but be made less focused, and there would be little to no negative consequences for patients. We're clearly missing a huge opportunity to save costs if that's true.

I don't know that I'd call FM training "focused" as it currently stands. It's not supposed to be, though, because family physicians are generalists. What's more, academic family medicine training environments are not at all reflective of community-based practice. A better criterion though is whether the demise of the rotating internship and general licensure has helped primary care availability and portability. 

I have to say though, I think you hit the nail on the head as to why I think having GPs with only a year of unfocused training are potentially hazardous to patients - they don't know what they don't know. I agree, there's always more to know, but I'm not concerned about a GP coming across a disease they've never seen before and being stumped. I'm concerned about a physician treating a patient and thinking they did a good job because no one's around to tell them otherwise. Residency is the last time physicians are truly supervised, where actions that seem like they work, but actually don't, can be corrected. Physicians lack feedback mechanisms, especially those in independent primary care practices. A GP who has spent minimal time in an actual primary care clinic may have all the medical knowledge they need, or the ability to obtain it, but won't have the practical experience necessary to tell an effective approach with a patient from an ineffective one.

I would not overstate the importance of an extra year of supervised practice. Simply put, residency is not the end of learning, but in some ways the beginning. It's one thing to make decisions and sign orders as a resident. When the buck stops with you, the responsibility is that much more important. I suppose an extra year gives some more time for a "safety net" before transition to practice, but I'm not sure that means very much. In the new CBD paradigm, assessment of competence is theoretically more fluid time-wise, but we will continue to have CME for a reason. You're touching on more fundamental issues with training and assessment that go beyond a set period of residency. 

The parallel I draw is to my own training in healthcare prior to medical school. It required a fraction of the knowledge medicine did and the job required a much smaller set of tasks to be performed. I can say pretty confidently that I had good mastery of my field's required knowledge before gaining significant clinical experience. Yet, to do that job, I still had a full year of clinical training which was far more applied and practical than anything I've gone through in medical school. Even after being fully certified, I was supervised by not only my more experienced co-workers, but the physicians I was working with, providing ample checks on my ability to do my job correctly. If I didn't know what I didn't know, they'd be able to catch me. When you say that GPs would be fine to practice after only one year of post-graduate training, what you're telling me that where I am right now, as a fresh MD grad, is only a year away from being a fully independent physician. Yet, it took me that long to train to do a less complicated job (though not a necessarily easier one), when I was starting from a much stronger position of knowledge relatively speaking, and which still required ample oversight to do safely. And you're telling me that'll all somehow get done with less focused training than I'm even going to get as an FM resident, which is itself less focused than what I got in my previous career. That doesn't add up to me. I've been a good student and I've worked hard to make myself as capable an incoming resident as I can be. At worst, I think I'm an average graduating student, but coming from someone who's been an independent healthcare practitioner before, I'm more than a year away from being able to practice medicine independently in a safe manner.

GPs were "fine to practice" after only one year not that long ago. What's changed since then has been ever-more emphasis on "lifestyle", +1 training, expensive imaging modalities, and a relative de-emphasis on basic clinical skills. As you point out, certification is not the same as competence, but it's also true that sitting and passing your exams does not make the equal of experienced colleagues. Experience - especially at missing something or being wrong - comes only with time and the most useful and educational part of it comes when you don't have that safety net. 

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On 6/22/2017 at 4:21 PM, A-Stark said:

I don't know that I'd call FM training "focused" as it currently stands. It's not supposed to be, though, because family physicians are generalists. What's more, academic family medicine training environments are not at all reflective of community-based practice. A better criterion though is whether the demise of the rotating internship and general licensure has helped primary care availability and portability. 

I would not overstate the importance of an extra year of supervised practice. Simply put, residency is not the end of learning, but in some ways the beginning. It's one thing to make decisions and sign orders as a resident. When the buck stops with you, the responsibility is that much more important. I suppose an extra year gives some more time for a "safety net" before transition to practice, but I'm not sure that means very much. In the new CBD paradigm, assessment of competence is theoretically more fluid time-wise, but we will continue to have CME for a reason. You're touching on more fundamental issues with training and assessment that go beyond a set period of residency. 

GPs were "fine to practice" after only one year not that long ago. What's changed since then has been ever-more emphasis on "lifestyle", +1 training, expensive imaging modalities, and a relative de-emphasis on basic clinical skills. As you point out, certification is not the same as competence, but it's also true that sitting and passing your exams does not make the equal of experienced colleagues. Experience - especially at missing something or being wrong - comes only with time and the most useful and educational part of it comes when you don't have that safety net. 

I think we're using different definitions of "focused". Yes, FM training is generalist training, but it still emphasizes primary care in an outpatient setting, because that's the job most FM doctors work in. I'll get half my first year in such a setting, while previous rotating internships would get, maybe a quarter of their time in such a setting? That's only a couple months training in the setting of work and that's where I think such a set-up would be severely lacking. It's not so much the knowledge gained, but the experience in a relevant setting. And yes, academic family medicine isn't the same as community practice (though the same could be said of any specialty) but it's far more similar than working in a CTU or on a surgical service, and FM residencies require some community training - something a rotating internship almost certainly wouldn't.

I fully understand the change that happens when you move from being a trainee to being an independent practitioner - I've already gone through that shift in my prior profession. I know that no amount of supervised training will make that shift seamless or remove the need to continue learning - a lot - once starting practice, especially in the first year. Yet, that fact does not eliminate the need for adequate training prior to independent practice. There are some lessons that can't be learned on your own and CME only does so much. Having been an independent healthcare practitioner, I know how easy it is to get away with bad habits and poor behaviours, while still being considered competent. Supervised training is the opportunity to correct these bad habits, a practitioners who don't develop good habits during their training don't develop them spontaneously on their own - there's simply little incentive for that to happen. Experience doesn't correct mistakes when you never get feedback that you've made a mistake. CME and on-the-job learning don't address these issues, yet they can significantly impact patient outcomes and healthcare efficiency in less-than-obvious ways.

I'd also like to note that while I think a single year of training is inadequate, I'm by no means defending our current training system, which is riddled with problems. Standards today for FM grads are below where they should be. Yet, cutting out a year of training to become a primary care provider only lowers those standards further. Yes, GPs were able to practice with only one year of training, but that was 25 years ago - a bit beyond "not that long ago", and the standards of practice at that time were even lower than they are today. Perhaps it was acceptable for a person with minimal experience in primary care to work as a primary care provider then. It isn't now, nor should it be. A rotating internship only works as a potential solution to unmatched graduates if we dramatically lower our standards on primary care providers - and, as it would do little to address that situation in the first place, I do not believe this is a worthwhile trade-off.

To over-simplify my objection to that proposal, we aren't going to move our medical system forward beyond the problems of today by repeating old ideas - and reintroducing old problems.

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I think the underlying problem here is the assumed value and "challenging work" of being a physician. Engineers do 4 years of training and are designing bridges, buildings, cars, and various other devices that can kill a lot more people faster and at higher cost than any physician error can. Even in the trades like gas or electrical, it's 2 years and error can easily result in death. So the idea that generalist physicians "need" an extra year of residency (i.e. CCFP vs rotating internship) to be competent I think is nonsense. Sure, there's a lot to know, but that extra year of residency is not going to teach you everything. As far as oversight goes, there is the college for MDs just as there is regulatory associations for other professions. In terms of immediate supervision, sure maybe engineers/trades have others double checking things, but that's also possible in family medicine. Don't know a Dx? Then don't mess around and refer to a specialist or send them to the ER if you're worried! As someone else pointed out, the most important thing is recognizing what you don't know and recognizing that a problem exists - then you can refer to someone else appropriately.

On this topic, I'd also put forward that residency is not and should not be a guarantee. Like any other professional school, there is no guarantee of getting a job after. Ask any law, PhD, engineering or arts student and see how difficult the real world actually is for jobs. It underscores that med students should have realistic expectations that success is not a guarantee, and maybe if students want to reduce risk of going unmatched, then perhaps a guns blazing approach for plastics or derm if your CV or contacts can't support it is unwise. So while it is absolutely unfortunate that many people go unmatched, that's just life in the real world with competition for jobs. Fortunately in medicine, despite job difficulty in some specialties and some students not matching, we still have a disproportionately impressive job rate post-university. It's a cost to the system paying to train unemployed doctors for sure, but 1) that's also the case for any other university trained student, and 2) there's also nothing stopping these unmatched MDs from getting a job in some other sector such as research, business, government, consulting etc.

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33 minutes ago, ZBL said:

I think the underlying problem here is the assumed value and "challenging work" of being a physician. Engineers do 4 years of training and are designing bridges, buildings, cars, and various other devices that can kill a lot more people faster and at higher cost than any physician error can. Even in the trades like gas or electrical, it's 2 years and error can easily result in death. So the idea that generalist physicians "need" an extra year of residency (i.e. CCFP vs rotating internship) to be competent I think is nonsense. Sure, there's a lot to know, but that extra year of residency is not going to teach you everything. As far as oversight goes, there is the college for MDs just as there is regulatory associations for other professions. In terms of immediate supervision, sure maybe engineers/trades have others double checking things, but that's also possible in family medicine. Don't know a Dx? Then don't mess around and refer to a specialist or send them to the ER if you're worried! As someone else pointed out, the most important thing is recognizing what you don't know and recognizing that a problem exists - then you can refer to someone else appropriately.

On this topic, I'd also put forward that residency is not and should not be a guarantee. Like any other professional school, there is no guarantee of getting a job after. Ask any law, PhD, engineering or arts student and see how difficult the real world actually is for jobs. It underscores that med students should have realistic expectations that success is not a guarantee, and maybe if students want to reduce risk of going unmatched, then perhaps a guns blazing approach for plastics or derm if your CV or contacts can't support it is unwise. So while it is absolutely unfortunate that many people go unmatched, that's just life in the real world with competition for jobs. Fortunately in medicine, despite job difficulty in some specialties and some students not matching, we still have a disproportionately impressive job rate post-university. It's a cost to the system paying to train unemployed doctors for sure, but 1) that's also the case for any other university trained student, and 2) there's also nothing stopping these unmatched MDs from getting a job in some other sector such as research, business, government, consulting etc.

One problem when comparing MDs to those other professions is that the MD degree has almost no flexibility to it on its own. If an engineering graduate cannot find a job in their preferred field, they have options to work in a related field or "do something else" to bide their time until their ideal job has opened up, as long as they hold a valid license to practice engineering. For a lawyer with a valid licence to practice law, if they can't get a job right away in their desired field/location, they have the option to practice in an underserviced area until their ideal position opens up. The key difference is that when you are in medicine, you are trained to do one specific job and cannot do anything else. After you get an MD, you are either a resident or you are nothing. You cannot work as a "half-clinician" anywhere, nor should you be able to, which essentially means that all of the training you have undertaken means nothing without the subsequent post-graduate training, and this is where most unmatched students get stuck doing graduate degrees or further clinical clerkship without pay. The jobs that you mention in research, business, etc. are available but are few in number, and certainly not anything close to the jobs these graduates have trained to do.

Perhaps a solution could involve opening up paid positions similar to residency spots in which the focus is on these unmatched candidates to help with the "grunt work" of residency without as much focus on teaching (similar to a physician assistant role), such that they provide a valuable service to the hospital without as much teaching responsibility from the hospital and a lack of focus on any one particular specialty. These spots could last 1-2 years, such that the trainee gains some exposure in basic clinical medicine, provides an "extra pair of hands" to the residents/staff (especially in overworked specialties) and can provide support on overnight call, while also being able to put food on the table until they get a formal residency spot.

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A significant number of unmatched physicians would have downstream consequences.  Consider financing - right now med students get large loans at prime (or better) rates.  If people started defaulting on their loans, which would be a logical choice, banks would stop extending large lines of credit with low interest rates (R1 salary with large debt).  Other professions that were mentioned (engineer, PhD, arts..), don't get access to large lines of credit from the bank.  However, PhDs do often get a little funding during their training since there's usually an attached work component (TA or research).  So if med school isn't necessarily easy now, imagine who difficult it would be with little financing.  I suppose if one is from a wealthy background, this wouldn't necessarily be a negative, since it wouldn't increase the number of applicants.

No one is suggesting that complacency is a great thing, but it's another thing to actually be in an unmatched position with little choices and a very large debt.  For example, the research job market is in general very poor.  About 10% of PhD land tenure track jobs, which are considered to be the 'prize' (much less in some fields).  An MD is a trained professional, but isn't any more qualified for most research positions than a PhD.  The pay in general isn't very high either.  

I don't think the average MD would have anything to offer over an MBA.  Robert Chu, the deceased, clearly was looking at gaining that credential.  But in addition to the debt incurred for the MBA, the individuals would be saddled with the debt for an MD, which is growing every year.    

I agree with the earlier suggestions of faculties taking responsibility through supporting their trainees and ensuring graduates do have options open to them.  More resources should be spent on candidate selection if there's a significant number of unqualified individuals going through a program.  Perhaps students should pressure faculties to teach more to the US MLEs?  The US seems to have an almost unlimited need for qualified professionals.  

   

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On 6/17/2017 at 11:02 PM, moonlitocean said:

Why on earth are there residency spots reserved for foreign trained med grads who decided to take the easy way by attending Caribbean schools with questionable credentials? Why aren't Canadian students prioritized? 

 

This is what happens when you let politicians manage the healthcare system.

At the end of the day it all has to do with costs and benefits. The government's responsibility is to provide healthcare services that are in their budget. Having IMGs (immigrants and Canadians who have gone abroad) is much cheaper than adding another seat. IMGs either had their own government fund their seat or they privately funded their education. Our government saves a lot by doing this.  

Having IMGs also  gives the royal college of physicians more control over foreign grads as they can dictate where they can work. Specifically in cases when they are immigrants to Canada. This allows the government to provide healthcare services in underserved areas. 

Also, IMGs who end up getting a residency spot are still discriminated as they are less likely to get a job at a teaching hospital.

I want to add that an IMG that gets a residency had to work a lot harder in med school and after med school compared to those who get in here. Foreign med schools are easy to get into, but very hard to get out of. I learned this while I was shadowing a family physician who was the preceptor for a PGY 2 in family med.  This resident was 22 years old and went to a 4 year med program somewhere in the Caribbean straight out of high school. She told me how she had to write the USMLE to try to get a spot in the U.S which she managed to as her clerkship years were spent in NY, then she also wrote the licensing exams for Canada as well as another country just  incase she didnt get a spot in the US or Canada. 

I think that if the government supplied the number of doctors needed to meet healthcare demands many physicians would be earning a lot less than what they currently earn as there would be less billing. 

We "pre-meds" need to realize that this profession is like any other. You're not guaranteed a specific spot just because we did xyz. We need to realize that sometimes things might not work out the way we wanted to. I realized this during my co-op working for a finance firm where I was more qualified academically and experience wise  than someone else, but because of their connects that person had the position I wanted. Although this is less likely in the medical profession it does happen more times than we think. 

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5 hours ago, mollypercocet said:

At the end of the day it all has to do with costs and benefits. The government's responsibility is to provide healthcare services that are in their budget. Having IMGs (immigrants and Canadians who have gone abroad) is much cheaper than adding another seat. IMGs either had their own government fund their seat or they privately funded their education. Our government saves a lot by doing this.

IMGs are not cheaper. It's also a complete waste of money to fund medical school spots that don't translate into practising physicians, which is exactly what the "unmatched" phenomenon can (sometimes) result in. It's a "sunk cost" that cannot be recovered. 

Having IMGs also  gives the royal college of physicians more control over foreign grads as they can dictate where they can work. Specifically in cases when they are immigrants to Canada. This allows the government to provide healthcare services in underserved areas.

The Royal College has nothing to do with "dictating" where anyone works. Indeed, it has nothing to do with that at all. Nor, I should add, do provincial colleges or provincial medical associations. Provincial governments, however, are sometimes involved in return-of-service contracts, which often come attached to those IMG residency spots. Most IMGs in rural areas are not "Canadians who have gone abroad". 

Also, IMGs who end up getting a residency spot are still discriminated as they are less likely to get a job at a teaching hospital.

It's hard to get an academic job for almost everyone. 

I want to add that an IMG that gets a residency had to work a lot harder in med school and after med school compared to those who get in here. Foreign med schools are easy to get into, but very hard to get out of. I learned this while I was shadowing a family physician who was the preceptor for a PGY 2 in family med.  This resident was 22 years old and went to a 4 year med program somewhere in the Caribbean straight out of high school. She told me how she had to write the USMLE to try to get a spot in the U.S which she managed to as her clerkship years were spent in NY, then she also wrote the licensing exams for Canada as well as another country just  incase she didnt get a spot in the US or Canada.

She had to work a lot harder by skipping an undergrad (or more!)? Uh-huh. How much medical training have you had to make such a comparison?

I think that if the government supplied the number of doctors needed to meet healthcare demands many physicians would be earning a lot less than what they currently earn as there would be less billing.

We "pre-meds" need to realize that this profession is like any other. You're not guaranteed a specific spot just because we did xyz. We need to realize that sometimes things might not work out the way we wanted to. I realized this during my co-op working for a finance firm where I was more qualified academically and experience wise  than someone else, but because of their connects that person had the position I wanted. Although this is less likely in the medical profession it does happen more times than we think.

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12 minutes ago, A-Stark said:

IMGs are not cheaper. It's also a complete waste of money to fund medical school spots that don't translate into practising physicians, which is exactly what the "unmatched" phenomenon can (sometimes) result in. It's a "sunk cost" that cannot be recovered. 

 

 

The Royal College has nothing to do with "dictating" where anyone works. Indeed, it has nothing to do with that at all. Nor, I should add, do provincial colleges or provincial medical associations. Provincial governments, however, are sometimes involved in return-of-service contracts, which often come attached to those IMG residency spots. Most IMGs in rural areas are not "Canadians who have gone abroad". 

 

 

It's hard to get an academic job for almost everyone. 

 

 

She had to work a lot harder by skipping an undergrad (or more!)? Uh-huh. How much medical training have you had to make such a comparison?

 

 

 

 

I opened my computer to write a reply but saw that you covered all the points I wanted to cover.

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7 hours ago, mollypercocet said:

At the end of the day it all has to do with costs and benefits. The government's responsibility is to provide healthcare services that are in their budget. Having IMGs (immigrants and Canadians who have gone abroad) is much cheaper than adding another seat. IMGs either had their own government fund their seat or they privately funded their education. Our government saves a lot by doing this.  

Having IMGs also  gives the royal college of physicians more control over foreign grads as they can dictate where they can work. Specifically in cases when they are immigrants to Canada. This allows the government to provide healthcare services in underserved areas. 

Also, IMGs who end up getting a residency spot are still discriminated as they are less likely to get a job at a teaching hospital.

I want to add that an IMG that gets a residency had to work a lot harder in med school and after med school compared to those who get in here. Foreign med schools are easy to get into, but very hard to get out of. I learned this while I was shadowing a family physician who was the preceptor for a PGY 2 in family med.  This resident was 22 years old and went to a 4 year med program somewhere in the Caribbean straight out of high school. She told me how she had to write the USMLE to try to get a spot in the U.S which she managed to as her clerkship years were spent in NY, then she also wrote the licensing exams for Canada as well as another country just  incase she didnt get a spot in the US or Canada. 

I think that if the government supplied the number of doctors needed to meet healthcare demands many physicians would be earning a lot less than what they currently earn as there would be less billing. 

We "pre-meds" need to realize that this profession is like any other. You're not guaranteed a specific spot just because we did xyz. We need to realize that sometimes things might not work out the way we wanted to. I realized this during my co-op working for a finance firm where I was more qualified academically and experience wise  than someone else, but because of their connects that person had the position I wanted. Although this is less likely in the medical profession it does happen more times than we think. 

The fact that those Carribbean schools are willing to take someone straight out of high school shows you just how little credibility they have. They will take anyone who is breathing and can write a cheque. 

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8 hours ago, moonlitocean said:

The fact that those Carribbean schools are willing to take someone straight out of high school shows you just how little credibility they have. They will take anyone who is breathing and can write a cheque. 

I think you don't really know how it works down there. They matriculate almost anyone, I don't disagree to this, but they won't let you move on if you don't have X% in your exams. So in the end they kick a lot of people out, so that they can maintain their "94%" USMLE score or whatever they advertise. 

Going right after med school is pretty much the norm all around the world except for North America. Although some schools in the US and Canada have started a 6 year program for competitive high school students. In those programs you're not guaranteed to get in after the 2 years. I think needing a bachelors before med school is ridiculous. Its just a way for Canadian universities to make more money. I feel that people who went to high school where advanced programs were offered should at a maximum have to do 2000 level courses to be able to apply.  Although this would be unfair to those of us who went to a rural high school where advanced programs were not offered I think that parents in rural communities would put more pressure on  school boards to provide a better education so that their children have the opportunity to apply to medical school at an earlier age. 

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39 minutes ago, mollypercocet said:

I think you don't really know how it works down there. They matriculate almost anyone, I don't disagree to this, but they won't let you move on if you don't have X% in your exams. So in the end they kick a lot of people out, so that they can maintain their "94%" USMLE score or whatever they advertise. 

Going right after med school is pretty much the norm all around the world except for North America. Although some schools in the US and Canada have started a 6 year program for competitive high school students. In those programs you're not guaranteed to get in after the 2 years. I think needing a bachelors before med school is ridiculous. Its just a way for Canadian universities to make more money. I feel that people who went to high school where advanced programs were offered should at a maximum have to do 2000 level courses to be able to apply.  Although this would be unfair to those of us who went to a rural high school where advanced programs were not offered I think that parents in rural communities would put more pressure on  school boards to provide a better education so that their children have the opportunity to apply to medical school at an earlier age. 

Quebec admits most of their medical students after CEGEP which is basically 2 years of advanced university-level courses after high school (which ends after year 11 here). It means that we can start 4 year programs after the equivalent of high school + 1 year in the ROC. Last I heard, our doctors turn out just fine!

I personally did 1 year of undergrad before getting acceptance and I'd say the only reason it helped was because it was in a health-related professional program. Otherwise, it probably would've been useless.

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10 hours ago, A-Stark said:

IMGs are not cheaper. It's also a complete waste of money to fund medical school spots that don't translate into practising physicians, which is exactly what the "unmatched" phenomenon can (sometimes) result in. It's a "sunk cost" that cannot be recovered. 

 

 

The Royal College has nothing to do with "dictating" where anyone works. Indeed, it has nothing to do with that at all. Nor, I should add, do provincial colleges or provincial medical associations. Provincial governments, however, are sometimes involved in return-of-service contracts, which often come attached to those IMG residency spots. Most IMGs in rural areas are not "Canadians who have gone abroad". 

 

 

It's hard to get an academic job for almost everyone. 

 

 

She had to work a lot harder by skipping an undergrad (or more!)? Uh-huh. How much medical training have you had to make such a comparison?

 

 

 

 

I agree with your point, but it's not like those who go unmatched are just going to drop their MD and move on to another career. They know that you'll apply in the next cycle. Most people who are unmatched are hoping to get into specialities where there is very little demand or are highly competitive. The process may not be the most efficient, but in no way is the government going to increase seats in those high paying competitive specialities. At the end of the day it ends up costing them more. Supplying more doctors will end up lowering wages which would lead to physician induced demand. This would be inefficient.  

There is also an issue of students looking down at those in family med and psychiatry. Both of these have more seats and their services are needed the most in the country. I think med schools should focus on exposing their students to psychiatry, family med and others for which there is a need.

 

Yes, but getting those jobs is harder if you're an IMG. 

 

Sorry, I wasn't clear. What she meant was that she would not recommend that pathway and when she got a  residency spot in Canada people told her you had it too easy and she just told me it's not that easy considering the financial burden (which is much more than just paying for an undergrad when you take out a LOC of over $200,000) and uncertainty of getting a residency spot. With all that stress she still managed to pass the USMLE, was offered a spot in the U.S, passed the Canadian requirements and passed the exams of the country her parents were from. IMO a person who was able to do all that at a very young age should not have to go through a useless undergrad...Regardless she still had to compete with other IMGs, luckily got into the program she wanted and saved upwards of at least $1.5 mill.  

 

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6 hours ago, mollypercocet said:

I agree with your point, but it's not like those who go unmatched are just going to drop their MD and move on to another career. They know that you'll apply in the next cycle. Most people who are unmatched are hoping to get into specialities where there is very little demand or are highly competitive. The process may not be the most efficient, but in no way is the government going to increase seats in those high paying competitive specialities. At the end of the day it ends up costing them more. Supplying more doctors will end up lowering wages which would lead to physician induced demand. This would be inefficient.    

Most people who are unmatched apply for competitive specialties and/or are restrictive in where they apply, possibly without backing up. (A few do have real red flags like failed rotations, etc.) Lately in the second iteration mosts spots have been francophone family medicine in Quebec with only scattered other things elsewhere. It's very tight. 

There is also an issue of students looking down at those in family med and psychiatry. Both of these have more seats and their services are needed the most in the country. I think med schools should focus on exposing their students to psychiatry, family med and others for which there is a need.

I don't think anyone "looks down" on FM and psych. Med schools have been on the family med bandwagon for years, though, especially with things like "rural weeks" and longitudinal integrated clerkships. 

Yes, but getting those jobs is harder if you're an IMG.

Not if you build up a strong academic profile, though that is the challenge. 

Sorry, I wasn't clear. What she meant was that she would not recommend that pathway and when she got a  residency spot in Canada people told her you had it too easy and she just told me it's not that easy considering the financial burden (which is much more than just paying for an undergrad when you take out a LOC of over $200,000) and uncertainty of getting a residency spot. With all that stress she still managed to pass the USMLE, was offered a spot in the U.S, passed the Canadian requirements and passed the exams of the country her parents were from. IMO a person who was able to do all that at a very young age should not have to go through a useless undergrad...Regardless she still had to compete with other IMGs, luckily got into the program she wanted and saved upwards of at least $1.5 mill.

No one forced her to undertake the "financial burden", and most Canadian med students have LOCs and accumulated debt in the six figures unless (possibly) they studied in Quebec, Manitoba, or NL. Rich kids can afford to start med school right after high school, but basically no one else ever could. 

How exactly did she save $1.5 million? 

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2 hours ago, A-Stark said:

I don't think anyone "looks down" on FM and psych. Med schools have been on the family med bandwagon for years, though, especially with things like "rural weeks" and longitudinal integrated clerkships. 

 

 

FM has always been looked down on because its too "easy". As for psychiatry people don't even consider them as a doctor. 

"Close examination of the social and academic environment in which young doctors are trained tends to be greeted with a degree of skepticism. The emphasis seems to be on specialization, rather than on the perhaps more humble—and less lucrative—pursuit of family medicine. If statements made in the CMAJ by students in Canadian medical schools are any indication, family medicine ranks very low on the medical specialty ladder.

In a letter to the editor, Dr Kuljit Sajjin wrote, “throughout my medical school training, family medicine was looked down upon as a career [at UBC]… [Once] I began my medical education I did not receive any encouragement to pursue this path until I actually spent time in a family practice elective. Unless attitudes toward family medicine change in our academic training centres, we can expect an American style system, where specialists outnumber family physicians." http://www.bcmj.org/mds-be/pride-and-prejudice-future-general-practice-canada

"I once met a medical student who had failed his first year exams. “It’s ok,” he said, as I tried to console him. “I know I’m not very bright, but I can always be a psychiatrist after medical school.”

Two years later, after I had professed an interest in psychiatry, a doctor told me: “You know you’re intelligent, right? You don’t have to do that – you could be a real doctor if you wanted to.”"

-http://blogs.bmj.com/bmj/2010/06/28/anna-mead-robson-psychiatry-–-a-specialty-for-failures/

Also, take a look at this: Lau, T. et al., 2015. Factors Affecting Recruitment into Psychiatry: A Canadian Experience. Academic Psychiatry, 39(3), pp.246–252.

Retaining physicians in rural and remote areas is more of an issue of whether the physician is being paid reasonably and if they grew up in a rural environment.  These are still an issue today. 

 

2 hours ago, A-Stark said:

No one forced her to undertake the "financial burden", and most Canadian med students have LOCs and accumulated debt in the six figures unless (possibly) they studied in Quebec, Manitoba, or NL. Rich kids can afford to start med school right after high school, but basically no one else ever could. 

How exactly did she save $1.5 million? 

You're absolutely right, it was after all her choice to go there.

You don't need to be rich to go to the Caribbean. My neighbor was able to put all 6 of his children through university and was able to send one of his daughters to the Caribbean and they're a middle class family. It just depends if you can be approved for a LOC with your parent as the co-signer. Schools in the US, Australia, and Ireland are far more expensive and so is the living cost there.

She saved $1.5 million+ because she's able to practice at the age of 23 instead of 28. So ~300K/year*5 (although if she decided to do a sub-specialty like most rural FMs do she could make upwards of $500K/year). 

 

 

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12 minutes ago, mollypercocet said:

She saved $1.5 million+ because she's able to practice at the age of 23 instead of 28. So ~300K/year*5 (although if she decided to do a sub-specialty like most rural FMs do she could make upwards of $500K/year). 

Is income tax taken into account there?

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38 minutes ago, mollypercocet said:

FM has always been looked down on because its too "easy". As for psychiatry people don't even consider them as a doctor. 

"Close examination of the social and academic environment in which young doctors are trained tends to be greeted with a degree of skepticism. The emphasis seems to be on specialization, rather than on the perhaps more humble—and less lucrative—pursuit of family medicine. If statements made in the CMAJ by students in Canadian medical schools are any indication, family medicine ranks very low on the medical specialty ladder.

In a letter to the editor, Dr Kuljit Sajjin wrote, “throughout my medical school training, family medicine was looked down upon as a career [at UBC]… [Once] I began my medical education I did not receive any encouragement to pursue this path until I actually spent time in a family practice elective. Unless attitudes toward family medicine change in our academic training centres, we can expect an American style system, where specialists outnumber family physicians." http://www.bcmj.org/mds-be/pride-and-prejudice-future-general-practice-canada

"I once met a medical student who had failed his first year exams. “It’s ok,” he said, as I tried to console him. “I know I’m not very bright, but I can always be a psychiatrist after medical school.”

Two years later, after I had professed an interest in psychiatry, a doctor told me: “You know you’re intelligent, right? You don’t have to do that – you could be a real doctor if you wanted to.”"

-http://blogs.bmj.com/bmj/2010/06/28/anna-mead-robson-psychiatry-–-a-specialty-for-failures/

Also, take a look at this: Lau, T. et al., 2015. Factors Affecting Recruitment into Psychiatry: A Canadian Experience. Academic Psychiatry, 39(3), pp.246–252.

Retaining physicians in rural and remote areas is more of an issue of whether the physician is being paid reasonably and if they grew up in a rural environment.  These are still an issue today. 

 

Quoting articles that are over a decade old or from another country does not provide any meaningful evidence for your point. The way both FM and psychiatry are viewed today has changed significantly since 2005 and is far different than what may be occurring in the UK.

I won't deny that there is a small subset of practitioners who look down on FM docs or psychiatrists. I've met a few of them along the way. However, it's no longer a widely held viewpoint and certainly not one that is endorsed on any sort of an institutional level. There's also a small subset of practitioners who look down on IM physicians, surgeons, and pretty much any other specialty, but as with FM and psychiatry, my experience has been that these are a distinct minority. To the extent that people shy away from these specialties, it's far more personal preference of what they want their own careers to look like, rather than looking down on the specialty - and those who choose it - as a whole.

By your other posts, it doesn't sound like you're in medical school yet, meaning you have less direct exposure on how these specialties are viewed by the specialty at large than most of the people on this forum. While this should never preclude you from sharing your own experiences and viewpoints on the matter, you're not in a position to lecture A-Stark, someone far deeper into the profession than you are, about what the general attitude in the profession happens to be. Along those like, I'd ask that please share your own opinion, rather than claiming to know what others think or believe.

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