Canada’s medical residency system is leaving some graduates in limbo

Robert Chu was a typical medical student in that he excelled at everything he did. He edited his high school newspaper and made it on the dean’s list in his undergraduate years. He volunteered to take notes for disabled students. After he got into medical school, he tutored hopefuls on the entry exam. “If somebody didn’t understand a concept, he was very good at explaining it to them in a manner that they could comprehend,” says his mother, Clara Chu. He was a skilled photographer and he loved to cook. Beef Wellington, macarons, homemade marshmallows. “Never anything simple,” his aunt, Cathy DeFazio, says with a laugh.

In his final year of medical school, it surprised everyone that he didn’t get a residency training spot, the important last stage of training to become a physician. He gained more job shadowing experience and reapplied the next year to a less competitive specialty. When he was again refused a spot, Rob Whyte, assistant dean of undergraduate medical education at McMaster University, took the rare step of personally writing him a strongly worded recommendation letter. “Unlike some other students where we are able to readily identify a concern in their file, Robert presents no such evidence and we remain collectively frustrated at his situation,” he wrote.

Robert, understandably, was the most frustrated of all, but he confronted the situation with the same resolve that had always worked for him. “He didn’t go halfway. It was all the way,” says Ms. DeFazio. He accessed and reviewed his reference letters – all glowing. He created flow charts of actions to take and people to contact. He wrote an impassioned letter explaining his plight and sent it to Prime Minister Justin Trudeau, then-Ontario Health Minister Eric Hoskins and others. There were a few sympathetic replies, but in the end, there was little anyone could do for him. He died by suicide in September 2016.

Suicide can have many factors and eludes simple explanations. No one can presume what led Robert to his death, but the stress and frustration he felt must have been enormous. What’s more, the situation he experienced and was trying desperately to expose is happening to others: a growing number of medical school graduates are not getting a residency training position required to practice medicine in Canada. In other words, more and more students are completing four or five years of intensive, not to mention costly, medical school training – only to find they can’t proceed to the next stage.

The residency application process is complicated, but to describe it simply, medical students apply – via the Canadian Resident Matching Service, or CaRMS – for residency positions at universities across the country in one or more specialties of their choice. The program committees select those they wish to interview, and then they rank the candidates. The medical school graduates in turn rank the programs, and an algorithm spits out a “match.” For those who don’t get matched, they can apply again over the next week for the remaining programs, often family medicine programs in small communities.

In 2017, 68 final-year medical students went unmatched after the second round. Another 31 went unmatched in the first iteration but chose not to apply to the remaining programs, which likely didn’t include their specialties of choice. These numbers don’t include all the prior-year graduates who had failed to match in previous years and were trying again. By comparison, in 2005, only seven students who competed in the second round remained unmatched. If the trend continues, there will be an estimated 140 graduating students who go unmatched in 2021, and 330 if you include those who are re-applying for a second time, according to the Association of Faculties of Medicine of Canada (AFMC).

In simple terms, more medical school graduates aren’t getting residency positions because the number of positions available has been decreasing in relation to the number of graduating medical students. “The most common reason a student doesn’t get matched is just musical chairs,” explains Anthony Sanfilippo, associate dean of undergraduate medical education in the faculty of health sciences at Queen’s University. A decade ago, there were about 114 residency positions for every 100 Canadian medical students, with internationally trained graduates filling the remaining positions. Today, there are 103 positions for every 100 Canadian medical school graduates.

That may seem ideal, but many Quebec-based residency positions are available only to those who can speak French, and in 2017 more than 50 of these francophone positions remained unfilled. So there are actually fewer English-language positions than there are graduates, explains Kaylynn Purdy, vice-president of education for the Canadian Federation of Medical Students (CFMS). “It comes down to the fact that no matter how good you are, someone has to go unmatched,” she says.

In this game of musical chairs, the stakes are high. For many, going unmatched is world-shattering. As Robert wrote in a letter sent to journalists and others, “My diligent studies of medical texts, careful practice of interview and examination skills with patients, and my student debt in excess of $100,000 on this pursuit have all been for naught.” For unmatched graduates, there’s the confusion about why they weren’t selected and the sudden uncertainty of the future. Students can apply when residency positions open up again the following year, but in the meantime, “you have resigned your fate to a year of being in limbo,” explains Aaron, a graduate who went unmatched in 2017 and asked to use a pseudonym. Feelings of social alienation often exacerbate the distress. “You go from being with this cohort of people for years and being quite close to them and they’re all celebrating and moving on with their lives and you’re not,” explains Ms. Purdy. “I’ve heard from some unmatched students that their classmates stopped talking to them because they didn’t want to make the person feel bad by talking about their residency, or the fact that they’re buying a house.” Clara Chu describes the phenomenon concisely: “Facebook,” she says, angrily.

The crisis is worrying everyone – medical student organizations, the residency program directors and the undergraduate program administrators. “The deans have clearly identified the unmatched Canadian medical graduate as a top priority,” says Geneviève Moineau, president and CEO of AFMC. Ravi Sidhu, the postgraduate dean at the University of British Columbia’s medical school, says “the unmatched medical student numbers are incredibly disconcerting. I can imagine how stressful it is.”

Who is going unmatched – and why – is difficult to grasp. Certainly, choosing a more competitive specialty can increase one’s risk of not getting a residency. In Robert’s first year of applying, he was one of 96 candidates vying for 81 radiology residencies. If family medicine had been his first choice, he would have almost certainly been matched – there were 200 more family medicine residencies than there were candidates who made the specialty their top choice. In 2017, obstetrics-gynecology was an especially competitive specialty, with 113 Canadian medical graduates vying for 77 residency spots. Paul Foster was one of the 36 ob-gyn hopefuls who didn’t match. His first reaction was self-doubt. “Maybe I screwed something up,” he thought, but then he heard of friends who suffered the same fate. “They’re superb candidates. It wasn’t the people with red flags,” he says.

Some argue it’s students’ own fault for choosing very competitive specialties and not wanting to go where they’re needed – especially family medicine. But it’s difficult to know from one year to the next whether a specialty will be in demand. Provincial governments set the number of specialty training spots each year, based on changing population needs. And students’ preferences can swing considerably from year to year. Many years, for example, neurology has had a one-to-one ratio of applicants to spots; last year, there were positions for only 70 percent of applicants.

Most of those who go unmatched are usually willing to do family medicine – more than two-thirds of graduates unmatched in the first round apply again in the second round to the remaining positions in family medicine and in small communities. But, here’s the clincher: the second round is also open to Canadians who have trained abroad. Last year, 1,811 internationally trained Canadians applied and 411 got positions. The directors of these programs often prefer a foreign-trained doctor whose first choice is family medicine, as opposed to a Canada-trained doctor who is choosing family medicine as a Plan B. As Dr. Moineau says, “family medicine can no longer be seen as a fallback.”

Perhaps the most egregious aspect of the matching process is that those who go unmatched are discriminated against upon reapplying. In the one application review Robert Chu was able to obtain, his failure to match the year before was mentioned in the red-flag category. A decade ago, when only a handful of students didn’t get matched, there were often clear reasons, like a professionalism issue mentioned on their medical school record, for example. Today, even though many of those going unmatched are stellar students, the stereotype remains. While almost 97 percent of final-year students are matched, only 65 percent of prior-year grads get matched, despite the fact that most have improved their resumés with an extra year of job shadowing and research. With each additional application year, the chances of matching are lower.

So what should be done? This past February, the AFMC, which represents Canada’s 17 faculties of medicine, released a list of recommendations to address the crisis of unmatched medical students. One of the most consequential suggestions is that international medical graduates no longer be allowed to apply for the positions that went unfilled in the first round, so that only graduates from Canadian medical schools can compete for these positions. (If this rule was in place last year, around 70 additional positions would have been earmarked for medical school graduates from Canada).

It will be up to provincial governments to decide whether or not to adopt this recommendation. But provincial ministries of health are also getting pressure from internationally trained doctors and their families. They’re Canadians, too, and they’re lobbying for more opportunity to do postgraduate training here.

Increasing the number of residency training spots would be one way to improve the prospects for budding Canadian-trained doctors. The AFMC is recommending that provincial funders work together to increase the minimum national ratio of one residency position for every current-year Canadian medical graduate. But that would cost money.

Residency programs at universities, meanwhile, have been instructed to improve fairness and transparency in the application process. In October, the AFMC board approved a document of best practices in resident selection. For instance, programs should “explicitly and publicly state the processes and metrics they use to filter and rank candidates.” As well, a medical graduate’s previous unmatched status shouldn’t factor into a decision. Enforcing these best practices is difficult, however, because applicants aren’t told why they weren’t selected. In Robert’s case, he wrote emails to directors, asking for feedback. “Not knowing what the problem is makes it very difficult to address,” he explained. All programs refused to provide any insight.

Kristina Arion, who went unmatched after applying for competitive ob-gyn residencies, likewise emailed program directors across Canada and was told, “Sorry, we provide no feedback.” Eventually, she got a single program director to review her file. He explained to her that candidates need all three referral letters to be exceptional. Though her letters were highly praiseful, one was written by an obstetrician who she worked with for less than a month; a letter from someone who had known her longer would have meant more. It was advice she found extremely helpful for this year’s application round.

Dr. Sidhu at UBC explains that schools don’t provide feedback because it would be unwieldy. A competitive program might have to choose 50 candidates to interview out of 400 applicants, he points out. But most of those who aren’t selected for one program will be matched with another, and therefore won’t need advice. The CFMS has proposed that unmatched applicants should get unique access to timely feedback from residency programs.

Undergraduate programs have a big role to play, too. Currently, some schools let unmatched students maintain their student status, so that they can access electives or job-shadowing positions. But other schools don’t offer an additional year. Doing electives can give students a leg up for the next year’s applications, which is why the CFMS is calling on all schools to extend student status to unmatched students. But paying a whole year of tuition isn’t great either, especially considering unmatched students are paying for electives only, not coursework. As it is, residency hopefuls are often paying to fly all over the country, first for electives and, secondly, for in-person interviews.

“Despite the stereotype of the medical student with the silver spoon in their mouth, when you’re racking up interest on your debts, you’re going to start to see people who have maxed out their credit and are trying to judge, ‘Can I afford to go to this interview?’” says Dr. Foster, who is currently paying another $25,000 so that he can do electives at Western University.

All undergraduate deans have agreed to begin “creating the structures” to support unmatched students, says Dr. Moineau, “including everything from extensive student affairs programs for unmatched students to creating the option for a fifth year.” The schools have agreed to report back to the AFMC by October with the changes they’ve implemented.

For the Chu family, the changes are too late. His family still doesn’t understand why he didn’t get matched. As Dr. Whyte wrote, all of his clinical placement supervisors rated him “consistently above average or exceptional.” He was “extremely well motivated,” said one letter. “His clinical examination skills were excellent,” read another. In yet another letter, Robert’s interpersonal skills towards patients and staff was described as “outstanding.”

“It’s not much consolation to be continually told I’ve done nothing wrong,” Robert wrote. Without a residency, the medical degree he had worked so hard to obtain had become, he felt, “effectively annulled.”

Postscript: Just before University Affairs went to press, Kristina Arion and Paul Foster both learned that they were successfully matched to a residency in the first round of 2018, held on March 1. Dr. Foster was matched to the northern remote stream at the University of Manitoba and Dr. Arion to the ob-gyn residency program at Dalhousie University. General numbers on the success of the 2018 matching process were scheduled to be released sometime in April.

Additional update: The numbers are now in for 2018. According to figures released on April 17 by the Canadian Resident Matching Service, there were 69 medical graduates who did not get a residency position this year after the second iteration of the residency matching process. Another 54 went unmatched in the first iteration who chose not to apply to the remaining programs. This compares to 68 and 31, respectively, in 2017. The two numbers combined, that’s a 24-percent increase in the number of unmatched medical graduates this year compared to last. These numbers don’t include prior-year graduates who tried again in 2018 to secure a residency but again did not get matched. This year, according to CaRMS, 57 of 133 prior-year graduates did get matched, a success rate of 57 percent.