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Interesting Program Directors Take on CARMS


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The basic sciences can be very important, but there is no sense in the current method of teaching. As it is currently, learning how to visually recognize certain histopathologic features/diseases on slides is utilized at most by 5% of each class. There are many basic science fields which are arguably more relevant to most clinicians (e.g. medical imaging physics for radiology, biomechanics for trauma/MSK) which are not taught--even nutrition typically only has a few basic lectures. A lot of the basic sciences taught in medical school is a holdover from a previous era, not because it's particularly important.

When training clinicians, it's backward to teach in depth the basic sciences first. Students only need the most basic of the physiology and pathophysiology knowledge before they are able to understand the disease. Once context has been established, i.e. the 'what', the smaller details become easier to retain and students are more eager to learn 'how' & 'why'.

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21 hours ago, bearded frog said:

I didn't say that we shouldn't learn relevant biochemistry, physiology, biology, physics whatever.... just maybe we don't have to memorize all the interleukins or devote as much time to interpreting pathology slides?

Considering there are constantly new biologics targeted at specific interleukins, I'd say it's still fairly important.

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21 hours ago, GrouchoMarx said:

I'm also a resident.

guess how many JVPs I've seen in the last three years? or how many babies I've delivered since medical school? or how many bones I've set?

that logic goes both ways.

I agree, don't teach the JVP. I'm not sure what your argument is here... we don't have a standardized test on how to deliver babies or set bones, as it may not be relevant for everyone. And I'm arguing that we should keep it that way!

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23 minutes ago, A-Stark said:

Considering there are constantly new biologics targeted at specific interleukins, I'd say it's still fairly important.

Well if you're a rheumatologist or immunologist then sure memorize then, otherwise I'd say do what everyone does now, and just look it up when needed.

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5 minutes ago, bearded frog said:

Well if you're a rheumatologist or immunologist then sure memorize then, otherwise I'd say do what everyone does now, and just look it up when needed.

They're kinda important to know about in rheum, derm, allergy, GI, GIM, heme, and probably more fields in the future. And it's not a matter of remembering all the pathways from first year on, but being exposed to them and then being able to understand the clinical application and mechanism of these agents. Looking up stuff is great and it's easier than ever to do that, but you really need to know stuff in the moment. Can't counsel a patient about a diagnosis or a treatment plan and be constantly checking UpToDate on your phone. 

Simply put, all that studying is actually pretty important and *matters*. Some basic science is less important, but you still need to see it. I really wish I'd gotten more physiology in pre-clerkship especially. Doing FIFEing clinical skills sessions only gets you so far. 

Otherwise I do think Step 2CK is probably the more relevant exam. The real problem with CaRMS, however, is that it reflects a system designed to shoehorn med students into the most defined terminal specialty possible at the earliest stage, with little more than an elective mix and maybe some research to show for it. Most applications seem interchangeable on paper and it's only a minority of applicants who really stand out during interviews. Rotating internships existed in a time when generalism was also more of a thing - we need to overhaul the system to try to bring back some of those benefits. 

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20 minutes ago, bearded frog said:

Well if you're a rheumatologist or immunologist then sure memorize then, otherwise I'd say do what everyone does now, and just look it up when needed.

To add to the above, some family drs also prescribe biologics. If you think we shouldn't know about them, then what separates us from midlevels? 

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4 hours ago, medigeek said:

To add to the above, some family drs also prescribe biologics. If you think we shouldn't know about them, then what separates us from midlevels? 

Family Drs shouldn’t be prescribing biologics - are you sure you saw this? They are immensely expensive and usually there’s a big process to go through for approvals so I thought it had to be from a specialist?

Separation from mid levels is fine and dandy but there also needs to be more regulation on what FMs can and can’t do. At current, their scope of practice is inappropriately broad in my opinion. 

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6 hours ago, ZBL said:

Family Drs shouldn’t be prescribing biologics - are you sure you saw this? They are immensely expensive and usually there’s a big process to go through for approvals so I thought it had to be from a specialist?

Separation from mid levels is fine and dandy but there also needs to be more regulation on what FMs can and can’t do. At current, their scope of practice is inappropriately broad in my opinion. 

That is supposed to give them the flexibility to somewhat specialize as well as I understand it - should any random family doctor do X? Probably not, but if one in particular decides to make it their area of interest and has a large part of their practice in that area what then?  There is a risk of too much siloing as well in medicine - the knowledge turn over is very high, and really you can function to a degree as a independent learner. It is not an easy balance of course :)

I know a family doctor that basically has their entire practice with HIV positive patients as an example. I would take that doctor over say an infectious disease specialist to do work in that domain.

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A good point that a senior faculty member at our school was bringing up at the beginning of first year is that they are well aware that it is impossible to remember everything we're taught with the immense amount of knowledge that's required to practice modern medicine. Instead, the point of being taught all of these tiny details is simply to remember that they exist so they can be looked up once they actually are useful. You can't look something up if you aren't even aware that it exists.

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7 hours ago, rmorelan said:

That is supposed to give them the flexibility to somewhat specialize as well as I understand it - should any random family doctor do X? Probably not, but if one in particular decides to make it their area of interest and has a large part of their practice in that area what then?  There is a risk of too much siloing as well in medicine - the knowledge turn over is very high, and really you can function to a degree as a independent learner. It is not an easy balance of course :)

I know a family doctor that basically has their entire practice with HIV positive patients as an example. I would take that doctor over say an infectious disease specialist to do work in that domain.

Flexibility, sure. But I think there’s also a point where ones training just doesn’t touch on certain topics and ”flexibility” turns into recklessness. Be it medical management or procedural - there’s some things that FMs are just not trained to do, yet there’s no rule restricting them from doing those things anyway. A radiologist dishing out biologics or cutting out a chunk of an ear with skin cancer would get sued and/or lose their license, but for a FM we just call it a practice interest. It just doesn’t seem right than an FM is allowed to deliver babies Monday, work the ER Tuesday, run an HIV clinic Wednesday, offer psychotherapy Thursday, and do clinic and office procedures/cosmetics Friday. Doubt many actually do this, but there’s nothing saying an FM can’t do this. We have specialists for a reason, so as flexible as FM is, I think there should be imposed limits. 

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On 4/29/2018 at 12:09 PM, rmorelan said:

That is a valid point I think - McMaster has always claimed their program is equivalent and this would be another way to show that in practice. It would actually be a powerful recruiting tool as well in a sense. In the US for instance the average USMLE score of the students is used to help attract people to the school. 

As you point out it would also partially remove some of the pressure of selecting a specialty so early - a standard test would be a universal currency in the matching process. You change your mind and at least you have that to stand on. Now you can spend a lot of time before you ready doing things that may not have any positive impact on your application in the end. It also means you won't be constantly trying to figure out as much about what a particular school's program in X is actually interested in - which honestly no one can clearly give you an answer to as it everyone just has a piece of the puzzle, and it changes quite frequently (PD for instance have a lifespan of about 5 years give or take on average and there are often shake ups when the change). 

 

Yeah... Mac claims that but... yeah its not true... at least for test scores. 

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5 hours ago, ZBL said:

Flexibility, sure. But I think there’s also a point where ones training just doesn’t touch on certain topics and ”flexibility” turns into recklessness. Be it medical management or procedural - there’s some things that FMs are just not trained to do, yet there’s no rule restricting them from doing those things anyway. A radiologist dishing out biologics or cutting out a chunk of an ear with skin cancer would get sued and/or lose their license, but for a FM we just call it a practice interest. It just doesn’t seem right than an FM is allowed to deliver babies Monday, work the ER Tuesday, run an HIV clinic Wednesday, offer psychotherapy Thursday, and do clinic and office procedures/cosmetics Friday. Doubt many actually do this, but there’s nothing saying an FM can’t do this. We have specialists for a reason, so as flexible as FM is, I think there should be imposed limits. 

Usually, a lot of FM mentioned in your example do a plus 1 year in obs, ER, HIV medicine, or psychotherapy...Your example mentioned above does happen, but they usually limit their practice to one- two areas of focus, for example: psychotherapy and HIV care. Once you accumulate clinical experience as a staff physician, you become quite comfortable managing your areas of interest. There is usually high need, and those doctors work in underserved areas. 

I just think that you do much more and learn quicker as a staff physician, as you are on your own now! 

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22 minutes ago, LittleDaisy said:

Usually, a lot of FM mentioned in your example do a plus 1 year in obs, ER, HIV medicine, or psychotherapy...Your example mentioned above does happen, but they usually limit their practice to one- two areas of focus, for example: psychotherapy and HIV care. Once you accumulate clinical experience as a staff physician, you become quite comfortable managing your areas of interest. There is usually high need, and those doctors work in underserved areas. 

I just think that you do much more and learn quicker as a staff physician, as you are on your own now! 

That’s fair, some are actual accredited +1 years, but others are not - certainly use of biologics is not one of those. But I disagree with the concept of clinical experience substituting for actual training, because to get that experience you have to be doing something you weren’t trained to do in the first place, like prescribing biologics. Weekend courses don’t make up for this. If that were the case, why do we even have specialists and royal college exams to ensure competency in specific areas? The other issue of course is that with so many FMs taking advantage of the broad scope of practice and doing things other than actual FM, the flood gates become wide open for more mid levels doing primary care. 

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2 hours ago, ZBL said:

That’s fair, some are actual accredited +1 years, but others are not - certainly use of biologics is not one of those. But I disagree with the concept of clinical experience substituting for actual training, because to get that experience you have to be doing something you weren’t trained to do in the first place, like prescribing biologics. Weekend courses don’t make up for this. If that were the case, why do we even have specialists and royal college exams to ensure competency in specific areas? The other issue of course is that with so many FMs taking advantage of the broad scope of practice and doing things other than actual FM, the flood gates become wide open for more mid levels doing primary care. 

I am not sure that FM doctors are taking advantage of the broad scope of practice and doing things than <<actual FM>>.

If you have done rural family medicine (where I did my core clerkship) rotation, the family doctors in small rural community are usually required to do in-patient hospitalist, emergency medicine, palliative care and obstetrics while doing some part-time outpatient office work. The CFPC want to train comprehensive family physicians who can work at all settings (urban vs rural) , and handle patients from all ages and all walks of life

What FM doctors do in urban GTA + Vancouver does not represent the reality of family medicine in rural and remote regions, where there is one general internist covering ICU+CCU, one obs-gyn for C-sections and high-risk vaginal delivery, and no FRCPC for ER in your hospital. You are by-default the <<physician>> in the hospital. 

We do have a lot of specialists in big cities, as if you go further just 2-3 hours of Toronto, the community GPs do a lot more than <<actual FM>> that you mentioned. There are not that many specialists in smaller cities and community, so the GP becomes more proficient for their patients' best interests. Do you want a 3 month old infant to wait 3-4 months to see a general pediatrician for failure to thrive?

If you can go through 4 years of medical school training, and successfully completed FM residency with rotations in every discipline of medicine, I don't see why can't a rural GP have a more broad scope of practice. 

I personally are not a big fan of NP-trained <<family physicians>>, their training is far less rigorous compared to a fully-fledged family physician, we are lowering the standard of primary care by allowing midlevel providers. 

p.s: what does prescribing biologics mean???

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18 hours ago, ZBL said:

Family Drs shouldn’t be prescribing biologics - are you sure you saw this? They are immensely expensive and usually there’s a big process to go through for approvals so I thought it had to be from a specialist?

Separation from mid levels is fine and dandy but there also needs to be more regulation on what FMs can and can’t do. At current, their scope of practice is inappropriately broad in my opinion. 

It's not hard to provide standard of care in an area of interest, even if you don't have formal training in it. Procedures/surgery is the very obvious exception to that. 

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2 hours ago, ZBL said:

That’s fair, some are actual accredited +1 years, but others are not - certainly use of biologics is not one of those. But I disagree with the concept of clinical experience substituting for actual training, because to get that experience you have to be doing something you weren’t trained to do in the first place, like prescribing biologics. Weekend courses don’t make up for this. If that were the case, why do we even have specialists and royal college exams to ensure competency in specific areas? The other issue of course is that with so many FMs taking advantage of the broad scope of practice and doing things other than actual FM, the flood gates become wide open for more mid levels doing primary care. 

You're right.. we should let NPs do it instead. lol. (and yes seen that suggested by an NP)

Unless you have evidence these doctors aren't providing standard of care, then why oppose it? Plus who is going to do it? The patient will need to wait an extra 3 months to see the specialist, suffer and get the same drugs/outcome. A small % of cases are certainly too complex for the FM and those will go to the appropriate doctor. 

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5 minutes ago, medigeek said:

It's not hard to provide standard of care in an area of interest, even if you don't have formal training in it. Procedures/surgery is the very obvious exception to that. 

I second that! Currently doing residency in a disadvantaged urban FHT, I manage a lot of infectious diseases patients (newly diagnosed HIV +, hep C) under my staff physicians' supervision, with a lot of mental health patients (doing some psychotherapy, starting depot injection for schizophrenia patients), starting ETOH UD patients on Naltrexone, etc..... feeling already comfortable managing a lot of complex patients, and I am doing FM residency at an urban area. I could imagine that my FM colleagues are doing even much more!

If you read around and constantly learn around cases, and have good exposure during your FM residency, I don't see why can't a FM physician have a broad scope of practice tailored to their interests?

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50 minutes ago, medigeek said:

It's not hard to provide standard of care in an area of interest, even if you don't have formal training in it. Procedures/surgery is the very obvious exception to that. 

So then what’s the point of specialist training at all, if FM is a ticket to doing whatever you want without proper credentialing? Just because you feel comfortable in managing a medical situation or procedure does not equate to doing it right or well. 

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10 minutes ago, ZBL said:

So then what’s the point of specialist training at all, if FM is a ticket to doing whatever you want without proper credentialing? Just because you feel comfortable in managing a medical situation or procedure does not equate to doing it right or well. 

I am not sure if you understand that FM doctors who have a broad scope of practice, i.e: full-time ER, FM obs, palliative care doctor, psychotherapists work in underserved area or rural & remote area, where is no or limited access to specialists? 

Also I don't understand what you meant by credentialing? What out-of-scope FM practice have you seen? By all means, a FM doctor is entitled to work in EM full-time, inpatient hospitalist, palliative care, doing vaginal deliveries, treating schizophrenic patients, and managing acute sick patients ? 

After you graduate from FM residency, you should be comfortable to have a broad scope of practice, or tailored to your own interest. GPs do refer complex patients to specialists, but the goal of family physicians is to be comfortable managing patients from all ages, with undifferentiated clinical presentation, and refer to specialists if patient becomes too complex or need a second opinion. 

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29 minutes ago, ZBL said:

So then what’s the point of specialist training at all, if FM is a ticket to doing whatever you want without proper credentialing? Just because you feel comfortable in managing a medical situation or procedure does not equate to doing it right or well. 

There are nurse practitioners doing specialist work and they're not even 1/10th as qualified as an FM. You need to evaluate the whole system rather than pinpoint FMs. 

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35 minutes ago, medigeek said:

There are nurse practitioners doing specialist work and they're not even 1/10th as qualified as an FM. You need to evaluate the whole system rather than pinpoint FMs. 

I second this thanks medigeek. They are NPs specialized in primary care, general surgery, pediatrics, obs-gyn, psychiatry (etc, you name it) who is working as a senior resident with minimal or no supervision at academic hospitals; with bachelor in nursing, and 2 years of master ----> acts a senior resident in all specialty. In primary care, the NPs roster patients under their names, with no physician supervision. 

Family physicians are by definition trained to provide care in broad scope of practice, the CFPC has been promoting comprehensive physicians to work in all settings, especially in underserved rural areas where there is little or no access to specialist care, and you have to become proficient and provide all level of care from cradle to grave.

To @ zbl, it is just not feasible to have a cardiologist nor GI in a small town with 10,000 k people; often the family physician runs the show in the hospital, and asks for their specialists colleagues only for complex cases. 

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4 hours ago, LittleDaisy said:

I am not sure if you understand that FM doctors who have a broad scope of practice, i.e: full-time ER, FM obs, palliative care doctor, psychotherapists work in underserved area or rural & remote area, where is no or limited access to specialists? 

Also I don't understand what you meant by credentialing? What out-of-scope FM practice have you seen? By all means, a FM doctor is entitled to work in EM full-time, inpatient hospitalist, palliative care, doing vaginal deliveries, treating schizophrenic patients, and managing acute sick patients ? 

After you graduate from FM residency, you should be comfortable to have a broad scope of practice, or tailored to your own interest. GPs do refer complex patients to specialists, but the goal of family physicians is to be comfortable managing patients from all ages, with undifferentiated clinical presentation, and refer to specialists if patient becomes too complex or need a second opinion. 

 

3 hours ago, medigeek said:

There are nurse practitioners doing specialist work and they're not even 1/10th as qualified as an FM. You need to evaluate the whole system rather than pinpoint FMs. 

Forgive me for being facetious - I know NPs are nowhere near as qualified as FMs, and that was intended as a tongue in cheek comment. I fully recognize that FMs need to be trained to have a broad scope of practice so they can cover whatever comes their way in rural settings, and in these cases I'd say sure they probably need to know the basics of getting things stabilized. However, I think this still has limits such that a FM should not need to utilize the full scope of their allowable practice  - just because someone comes in with a new onset of vasculitis, doesn't mean the FM is or should be the one to set them up on Rituximab, even if they know that's on the treatment pathway. It would be negligent to think this could be managed on their own. By the same token, I don't know of any single example whereby a FM should be starting a biologic. Give the steroids (even this is questionable for things like MS with crazy high doses), get it settled, then consult the specialist. Back in the day FMs would do burr holes, appendectomies, colonoscopies (and some still do according to the US AAFP webpage), but this is historic and there should be no real need for them to do these things today. 

 

However, most FMs are not working rurally, and my original argument was really intended for urban medicine. In an urban setting, even more so, there is no need for FM to be exercising the full scope of their practice given access to specialists - urgent things go to the hospital and it's dealt with quickly. In urban centres, we are still seeing many FMs take on areas of focused practice, which maybe does serve some need for specialized subacute care, but also takes away from needed resources to cover general family practice - which is why I brought up the midlevels comment. Despite this, some FMs do operate perhaps beyond their capabilities, yet still technically within their scope. For instance, I've seen a couple rogue FMs thinking they are plastic surgeons and start ripping off skin leaving horrible scars, asymmetry or missing pieces of face. Technically it is within their scope of practice according to how we have things set up, but just because you can doesn't mean you can do it well or that you should. Same deal for other procedural work or medical management like biologics, heart failure etc, just because you can follow the treatment pathway or saw it once in residency, it doesn't make you an expert. I've seen many cases of things where there is a serious delay in referral to a specialist because the FM has a self-proclaimed interest in the area and their approach failed.

 

All I'm saying is that while these focused practice areas are nice from a career standpoint and are perhaps necessary to serve some community need, and certainly do in rural settings, I think it's incorrect to presume the practice capabilities and outcomes (when exercised to the full extent) are equivalent to what could be done under a specialists care - that is why we have specialists after all, just as it would be incorrect for a cardiologist to start seeing walk-in patients for knee pain in downtown Toronto.  So when those physicians are doing that in an urban setting, with access to specialists readily available, I question why that is the case.

 

Of course this whole discussion came up because @medigeek suggested FMs were giving biologics. I really doubt that’s the case, from a practical perspective, training perspective and insurance perspective (I doubt any insurance company is going to hand out 30K per year drugs without a specialist consult). 

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7 hours ago, ZBL said:

 

Forgive me for being facetious - I know NPs are nowhere near as qualified as FMs, and that was intended as a tongue in cheek comment. I fully recognize that FMs need to be trained to have a broad scope of practice so they can cover whatever comes their way in rural settings, and in these cases I'd say sure they probably need to know the basics of getting things stabilized. However, I think this still has limits such that a FM should not need to utilize the full scope of their allowable practice  - just because someone comes in with a new onset of vasculitis, doesn't mean the FM is or should be the one to set them up on Rituximab, even if they know that's on the treatment pathway. It would be negligent to think this could be managed on their own. By the same token, I don't know of any single example whereby a FM should be starting a biologic. Give the steroids (even this is questionable for things like MS with crazy high doses), get it settled, then consult the specialist. Back in the day FMs would do burr holes, appendectomies, colonoscopies (and some still do according to the US AAFP webpage), but this is historic and there should be no real need for them to do these things today. 

 

However, most FMs are not working rurally, and my original argument was really intended for urban medicine. In an urban setting, even more so, there is no need for FM to be exercising the full scope of their practice given access to specialists - urgent things go to the hospital and it's dealt with quickly. In urban centres, we are still seeing many FMs take on areas of focused practice, which maybe does serve some need for specialized subacute care, but also takes away from needed resources to cover general family practice - which is why I brought up the midlevels comment. Despite this, some FMs do operate perhaps beyond their capabilities, yet still technically within their scope. For instance, I've seen a couple rogue FMs thinking they are plastic surgeons and start ripping off skin leaving horrible scars, asymmetry or missing pieces of face. Technically it is within their scope of practice according to how we have things set up, but just because you can doesn't mean you can do it well or that you should. Same deal for other procedural work or medical management like biologics, heart failure etc, just because you can follow the treatment pathway or saw it once in residency, it doesn't make you an expert. I've seen many cases of things where there is a serious delay in referral to a specialist because the FM has a self-proclaimed interest in the area and their approach failed.

 

All I'm saying is that while these focused practice areas are nice from a career standpoint and are perhaps necessary to serve some community need, and certainly do in rural settings, I think it's incorrect to presume the practice capabilities and outcomes (when exercised to the full extent) are equivalent to what could be done under a specialists care - that is why we have specialists after all, just as it would be incorrect for a cardiologist to start seeing walk-in patients for knee pain in downtown Toronto.  So when those physicians are doing that in an urban setting, with access to specialists readily available, I question why that is the case.

 

Of course this whole discussion came up because @medigeek suggested FMs were giving biologics. I really doubt that’s the case, from a practical perspective, training perspective and insurance perspective (I doubt any insurance company is going to hand out 30K per year drugs without a specialist consult). 

The common practice in urban family medicine is that a lot of GPs refer to specialists too easily, without a proper history nor work-up, which could eventually delay sick patients needing to see specialists sooner. The example that you described of urban FM doctors prescribing biologics is uncommon, usually those biologics are prescribed by specialists as you mentioned. 

I think that we need to train competent family physicians who refer patients to specialists with a proper work-up and clinical examination, knowing whom to refer and whom we could follow-up in primary care. Eventually, as the population is aging and becoming medically complex, GPs are gatekeepers of the use of health resources and accessing to specialists. I find that a lot of urban GPs over-refer knowing that there are many specialists easily accessible, which will become more difficult as the government reduces the residency training positions in specialties and the aging population becomes high-need. 

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