Little room for error in Canada's postgraduate training system
Sandy Robertson
CMAJ 1997;156:682-4
[ en bref ]
Sandy Robertson is a freelance writer living in Ottawa.
© 1997 Sandy Robertson
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In brief
Although the majority of physicians entering residency training in Canada will enjoy fulfilling careers in their chosen specialty, today's postgraduate training system has its critics. Among them are the new graduates who are not satisfied with the residency positions offered to them and practising physicians who would like to re-enter the system to train in a new specialty but find themselves locked out.
En bref
Même si la majorité des médecins qui entreprennent une formation en résidence au Canada feront une carrière profondément satisfaisante dans la spécialité de leur choix, le système de formation postdoctorale d'aujourd'hui a ses critiques. On compte parmi eux la poignée de nouveaux diplômés qui ne sont pas satisfaits des postes de résidence qui leur sont offerts et les médecins actifs qui aimeraient réintégrer le système pour suivre une formation dans une nouvelle spécialité mais qui se trouvent exclus.
Most Canadian physicians who complete residency training will be happy with their choice of specialty and gladly spend their career in it. But for the handful who have made the wrong decision, no subject is more fraught with anger and frustration than their current inability to enter a new postgraduate-training program.
They are caught in a situation that is unexpected and beyond their control. Some see it as a tragedy, but if it is, it is a tragedy without a villain. The real problem may be that today's undergraduates must determine their career path when many of them are too inexperienced to make such a choice. If they make the wrong decision they are often stuck with it, because the current system allows little margin for error.
Where did the problem start? When the College of Family Physicians of Canada deemed that family practice demanded additional training and knowledge, it followed that licensure to practise would only be granted after a 2-year program in family medicine or completion of specialty training in another area; the 1-year internship had disappeared. This meant that new graduates required additional residency positions because training now lasted longer. As a result, many fewer position were available for practising physicians wishing to retrain. "I don't believe anyone realized the full extent of the hardship this would cause," says Eva Ryten, director of research at the Association of Canadian Medical Colleges.
The new system was at odds with tradition. Previously many young doctors left for small towns after 1 year of postgraduate training, armed with a licence and the desire to gain experience and repay their financial debts. But many considered their first stab at medical practice a stepping stone to the specialty training they would choose after they had a few years' experience under their belts. Today that option does not exist, and those who were in practice before the system changed have found that most training posts are reserved for new graduates. Finding a retraining position in another specialty is difficult, if not impossible.
Physicians who chose a career path several years ago offer many reasons for wanting a career change. They may find themselves either unsuited to their field or burned out because of its demands, situations that bode ill for physicians and patients alike.
Dr. Michele Hultzer is typical of physicians facing this problem. She first went into family practice in western Manitoba, where she "enjoyed teaching the medical students but gradually realized that general practice was not for me. Much of the work consists of trying to deal with psychosocial problems -- problems I couldn't solve, people I couldn't help. This wasn't why I studied medicine." Unable to enter even the specialties in short supply in western Manitoba, Hultzer eventually moved to Winnipeg to do emergency work.
Dr. Donna McClure, a British Columbia family practitioner who is also involved in ER work, describes the constant frustration of dealing with demanding patients who don't appreciate the help they receive. "I find they take very little responsibility for their own health. [Their] first words are, 'I want a referral.' I am not a referral robot."
Other young physicians, reluctant to speak openly or unwilling to identify themselves for fear of risking their chance of finding a residency opening, express bitter disappointment about their inability to train as specialists. Many who enjoyed a few years of general practice now want to increase their knowledge and competence by completing a residency program. Some are willing to provide badly needed specialty care in remote areas if they get the training they want. In the end, those desperate for a career change but unable to alter their career path face a bleak and uncertain future.
Dr. David Atwood of the University of Ottawa, the Ottawa General Hospital's representative with the Professional Association of Internes and Residents of Ontario, considers himself lucky. He first chose to specialize in surgery, never considering a career in psychiatry. "When I started in surgery," he explains, "I loved the actual technique but hated what you had to do, having people waiting hours for a 5-minute visit." Atwood became interested in the "people" aspect of medicine and was able to switch to psychiatry. "I hate to think what would have happened to me and to my patients if I had stayed in surgery."
Dr. Fred Saibil, head of gastroenterology at Toronto's Sunnybrook Health Science Centre, also worries about what happens when physicians like Atwood aren't able to switch specialties. "It's ridiculous!" he says. "Imagine being operated on by a surgeon who decided halfway through surgery that he has no interest in it. Doctors who are bored with what they are doing carry a risk to their patients."
Postgraduate training poses particular challenges in specialties such as psychiatry and laboratory medicine, neither of which ranks particularly high in popularity among new graduates but may prove attractive to physicians who have been in practice for several years. Dr. Neil Levitsky, a Toronto psychiatrist, believes that "the best psychiatrists are often those with maturity after years of personal growth, and current restrictions rule out these older candidates [and] disastrously lower the pool of future psychiatrists."
Practising physicians who want further psychiatry training to help meet patients' psychosocial needs may find it is not available. (Even some psychiatry residents who take time off for financial or other reasons find that they cannot re-enter the field. Dr. Ambrose Cheng of Toronto interrupted his psychiatry residency for urgent family reasons, and now finds he cannot return.)
"To put it succinctly," comments Dr. Robert Durnin, a specialist in physical medicine and rehabilitation in Windsor, Ont., "I think the present system stinks and is a great disservice to our students and to the public at large."
Although laboratory medicine remains relatively unpopular with new graduates, probably because of its lack of patient contact, its challenging scientific aspect may appeal to experienced clinicians. Dr. Rocke Robertson of Barrie, Ont., who chairs the Ontario Medical Association's Section on Laboratory Medicine, was once a generalist "burned out after 4 gruelling years of . . . dealing with incredibly large numbers of people who presented with socioeconomic problems that were not solvable medically." He has never regretted his decision to switch to laboratory medicine, but confirms that the fields of pathology and laboratory medicine are not considered attractive by most medical students choosing their future careers.
Perhaps it lies with those established in these specialties to turn the spotlight on the problem. Dr. William Maurice, an associate professor and head of the Division of Sexual Medicine in the Department of Psychiatry at the University of British Columbia, formed an ad hoc committee last spring to tackle the issue, and it was a driving force behind a motion delivered to the CMA's 1996 annual meeting by the British Columbia Medical Association. The motion, introduced by Dr. Derryck Smith, the BCMA president, said the CMA should convene a national meeting to address "the crisis in postgraduate medical education" that forces students to choose a specialty too early in their career and provides "almost no opportunity to re-enter training after a period in practice." The motion passed.
Nova Scotia is looking at the problem on its own. Dr. James Goodwin, chief of the Department of Obstetrics and Gynaecology at the Yarmouth Regional Hospital, will chair a Working Group on Professional Licensing and Postgraduate Medical Education in that province.
However, Sandra Banner, executive director of CaRMS -- the Canadian Residency Matching Service -- says the new system is more accountable, and better counselling and guidance are available to students who are choosing a specialty. Although she agrees that those already in practice face restrictions if they pursue retraining, she is more optimistic about physicians just starting their careers. "Many graduates request and are offered a change," she says. "More than 200 successful changes were made this year alone."
Although there is an air of panic before match day, most students appear to settle down well. She already sees improvements, and thinks recent graduates are much more relaxed about the new system.
Surgeon Allan Taylor, an assistant professor at the University of Ottawa, hopes that is true. "I deplore that many of our future physicians will have been directed by expediency along unsuitable career paths. As a teacher of medical students for the past 30 years, it concerns me. As a prospective patient, it frightens me."
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