Skip to main content
Improving Physician Training

Improving physician training in 2019*: Can a quartet of changes reduce trainee stress and debt and enhance the breadth of their clinical expertise, without prolonging training?

This blog discusses increasing challenges faced by Canadian medical students and residents that are causing students to accumulate debt and experience stress while diverting them from clinical training. The blog makes the case for four changes: 1) increase residency training positions to meet Canada’s medical needs and, in parallel, simplify the Canadian Resident Matching Service (CaRMSprocess for allocating residency positions, 2) limit external electives in medical school3) delay selection of medical career tracks until first year of residency and 4) restore the rotating internship. The blog is not a criticism of our trainees, medical schools, residency training programs, CaRMS or the Royal College of Physicians and Surgeons of Canada (RCPSC); rather it is the well-intentioned perspective of an informed outsider. I’m not an expert in medical education; rather, I draw on my experience as a physician who has trained and practiced at multiple Universities in Canada and the USA. Medical training was not perfect when I trained and it’s not perfect now. However, having enjoyed teaching and mentoring since 1988, I am concerned by the hyper-evolution and proliferation of distractors and stressors, which I believe contribute to trainee stress and burnout. These factors are also counterproductive to the creation of the broadly skilled physicians. I offer my personal perspective on how we might deal with these problems drawing on the best of the old system of training while retaining the best of the new.  

 

The following opinions are my own and do not reflect the views/policy of Queen’s University or the Faculty of Health Sciences. 

 

 

We are training doctors for the public. What does the public want? After 30+ years of practice I can confidently say that the public wants us to produce a steady supply of physicians who are content experts and masters of their profession. They also expect physicians to emerge from training as compassionate and humane practitioners. They assume that we will enjoy our profession and will serve reliably over a 30-40 year career. In short, patients (and we are all ultimately patients) expect our medical schools and residency training programs to produce AAA doctors. An AAA doctor is one who is available, affable and able. How are we doing in the training of AAA physicians? I give us a passing grade; but there are signs that the system is fraying. Patients complain that they all too often encounter doctors who can’t or won’t deal with their health in a holistic manner (one problem per visit please!). Senior colleagues lament the lack of basic clinical and procedural skills in trainees emerging from residency programs. Meanwhile, trainees are complaining of burnout as early as first year in medical school. In light of such events I think it fair to ask whether the design of Canada’s medical schools and residency training programs is optimized to provide learners with the depth and breadth of clinical training needed to create the best possible physicians while supporting their wellness. 

 

Compared to when I trained, progress has occurred. We have (largely) eliminated shame-based learning, reduced duty hours to avoid exhaustion and impaired decision making and have improved the rigour of evaluation of trainee preparedness, by adopting competency based medical education, (CBME). CBME aims to improve our assessment of physician quality by ensuring frequent, well-documented evaluation of trainees. However, an unintended consequence of CBME is that specialty training programs are increasingly inward looking (narrower). They are less often sending their trainees to do rotations on services outside their own speciality. In the CBME era programs are too often satisfied if their trainees are competent in their own specialty, rather than pushing them to be broadly trained.  Moreover, we have moved away from high volume clinical training, relying increasingly on simulation of procedures and shorter clinical rotations. In 2019 rotations are often too brief for trainees and attending physicians to develop deep bonds which jeopardizes the quality of the training experience and the ability of the mentor to provide meaningful evaluation.  

 

If you are an older physician, the challenges faced by today’s medical students and residents may surprise you (they were not part of your training experience). If you are a current medical student or resident, this is the only system you know, so these “problems” may seem “normal”. If you are a lay person, you probably thought that we were better organized! Indeed, the public’s perception of how doctors are trained is stuck in a time warp. Many envision an earlier era, when young doctors followed older physicians through the hospital, learning apprenticeship-style, by caring for patients while serving lengthy rotations and working grueling hours. Times have changed! Trainees still work long hours, but their clinical rotations are short, fragmented and often geographically dispersed for reasons that are unrelated to the clinical value of the rotation.

 

We enter medical school as empathetic idealists, aspiring to improve human health. The goal of training is to build on this and equip us as experts in the practice of Medicine, based on a foundation of science, evidence-based medical knowledge, and clinical training. Our 3 or 4 years in medical school and 2-3 years in residency should also hone compassion and resiliency so that we can thrive while dealing with the joys and heartbreaks implicit in caring for people who are ill.  However, in the real world, the training and evaluation of medical students and residents has evolved insidious problems that add little value to the desired end product (a triple A doctor); but which do contribute to trainee stress and debt. Changes in our medical schools, particularly preoccupation with successful residency matching, a high school like fixation on exam preparation and a premature requirement to choose a career path, are stressing trainees and pulling them away from meaningful patient contact, thereby reducing experiential aspects of training and harming wellness.  Medical training in 2019 is influenced by complex factors, and some major components are unaligned with mission #1: (which is the training doctors about health and disease). Moreover the notion of learning by doing and the associated belief in the virtue of clinical service (during which one learns) has been challenged by the beliefs that clinical service is distinct from learning, and that excesses in service are to be carefully guarded against lest “education” be compromised. Modern medical training is also influenced heavily by the funding decisions of provincial governments (which limit the size of both medical schools and residency programs), hospital congestion (which impairs the quality of the learning environment), and well-intentioned, but ever-increasing, demands by examination bodies (RCPSC) and regulatory stakeholders, notably the Committee on Accreditation of Canadian Medical Schools (CACMS). In aggregate the many mandates imposed on our medical schools dilutes focus and risks making medical education a bit like a horse built by committee! Finally, the residency matching process(independently managed for the AFMC by CaRMS) has unintentionally transformed our medical students into peripatetic medical tourists. 

 

 

Horse Picture

 

Medical trainees are reporting burnout ever earlier in their careers. Burnout (defined as a lack of empathy and compassion and loss of the sense of self-worth) is occurring before the students have actually begun caring for patients or doing on-call service! The lack of trainee wellness also afflicts residents and is concerning, especially as it is occurring despite legislated restrictions in work hours and increased pay. Let’s consider some recent realities that may be driving burnout. In 2019, medical students worry whether they will match to a residency program upon graduation.They worry about the need to select a career track during their 2nd year in medical school (before they have meaningfully experienced most options). Career choices largely shape the students’ choice of electives and focuses much of their medical school experience on clinical rotations that are narrow (i.e. relevant to their chosen discipline). The fact that the curriculum forces medical students to prematurely select their vocation is new (I decided on my path after medical school, during my rotating internship-but more on that later). Premature restriction of focus not only stresses medical students, but also means that they will have had no practical experience in broad swaths of Medicine. This makes for more narrowly trained physicians who are less prepared to deal holistically with patients. Do we want narrowly trained physicians, or do we prefer all physicians to have mastered a broad base of medical knowledge/experience? I would argue we want the latter; for they will be more comfortable with the whole person and take a more holistic approach to their patients . In Medicine we often talk of the “hidden curriculum” (an allusion to biased subliminal communication that suggests one or another career path is more valuable/worthier). However, there is no greater bias (in my view) than not allowing these talented minds to experience the breadth of practice that comprises capital M, Medicine, before choosing a career! 

 

One colleague who leads a large training program disagrees with my view point, arguing I can’t think of any profession in which selecting a career tract takes more than 8 years of post-secondary education…. Further, we know that a lot of career tract switches happen after residency starts—they aren’t locked in. I also am not sure there’s any evidence to show that people who end up in second choice tracts have decreased job fulfillment.These are all good points, but I am not advocating longer training; rather I propose that we admit trainees to Medical school after 2 years of University and simply restructure the first year of a residency program into a rotating internship. This would offer benefits and no extension the duration of training would be needed. 

 

Canadian medical students are also stressed by the debt, many having borrowed $200,000 to complete medical schoolI acknowledge that tuition (~$20,000/year) is an important contributor to student debt. However, medical schools have limited funding streams, since they are prevented from expanding class size by the government and increasingly lack adequate base ministry funding to meet their mandate. So reducing tuition is an unlikely solution. More importantly, tuition is not the only driver for student debt; the CaRMS process, discussed below, engenders substantial expense. It is probably unfortunate for medical students that banks now offer them a $ 275,000 line of credit! Despite formal financial counselling (now part of our medical school curriculum), many trainees are slow to recognize that debt has a harsh hysteresis (easy to borrow; hard to repay). If tuition is immutable, we should eliminate other avoidable expenses where possible. 

 

One new and pernicious expense relates to the cost of off-site electives and CaRMS interview that see our medical students living on the road for 3-4 months of their training.  Off-site electives are done because of the perception they increase the medical students odds of a successful CaRMS match to a residency position at the end of medical school. In fairness, residency spots are recently in shorter supply in Canada than has historically been the case. In response, the modern medical student travels the country performing many, 2-week, elective rotations, effectively auditioning for a spot at site after site. This medical auditioning occupies ~3 months of medical school, incurs debt, elevates stress and does little to provide them with a balanced educational portfolio. In reality, 99% of Canadian trained medical students successfully match to a residency position; but perception is reality and when a match fails to occur the consequences can be dire (more on this later). In addition, with a “tight match” an individual’s professional and geographic preferences may not be met, which is a legitimate stressor.Once students are ultimately offered CaRMS interviews another cycle of stress and expense (and absence from the academy) begins, as they visit 10-20 programs. Both the proliferation of electives and the trans-national interview trips are new in the past decade or so.

 

As medical students enter residency training the genesis of their angst switches. Beyond the challenge of learning to be a good doctor, they begin to worry about passing their qualifying exams (Certification Examination in Family Medicine for family docs or Royal College exams, for all others). Most spend 6-9 months of nights and weekends in serious study mode;  time that would in part have been used for personal wellness, such as socializing with friends and family.  Exam preparation has morphed from something the old guard did in the course of service-based training, to a hurdle which takes 6-9 months of focused effort. Despite exam angst, 95% of Canadian trained residents pass their Royal college exams on the first attempt, a success rate that seems even higher than when I sat this exam in the 1980s. This time commitment might be justifiable were the questions on the exam reflective of “must know” content that is core to being a good doctor.  Despite efforts to reform the exam along these lines, many RCPSC questions are arcane, testing a fair bit of esoterica, as well as vital knowledge.  The stress however comes from studying for the esoterica! Per students and educators, I talked to, the much higher pass rate of Canadian trained students (versus US trained students who write the RCPSC exam, for example) reflects not only their focused preparation but also the recycling of 50% of questions which are leaked from year to year from one years’ test writers to the next). Some training program directors I talked to disagree. They argue the combination of clinical service (which does not stop while residents study) and intensive exam preparation creates a potent coherence that enhances knowledge retention. Moreover, the difference between Canadian and international trainee test success persists for the oral portion of the exam, which includes physical examination skills. There aren’t binders of old questions to study from for this part of the exam and thus, they argue the differences must be predominantly the result of superior preparation of Canadian students. However, the duration of intense studying is increasing year by year and, whether effective or not for passing the exam, is stressing residents, contributing to their burnout and also diverting them from personal wellness activities. It may also distract them from clinical and procedural opportunities that they could otherwise pursue.  In assessing the value of testing, we must always remember that doctors practice Medicine and Medicine requires practice!  

 

Another factor that challenges all medical schools are the proliferation of accreditation criteria which shape their mandate/curriculum. The American organization that accredits medical schools, the Liaison Committee on Medical Education External Link(LCME), also accredits M.D. programs in Canada, in cooperation with the Committee on Accreditation of Canadian Medical Schools (CACMS). The CACMS framework requires medical schools to meet 12 standards, each comprised of 6-12 elements. Thus, a total of 95 domains that must be satisfied to keep the medical school accredited. It is fair to say that approximately halfthe CACMS accreditation elements have little to do with the quality or quantity of hands on exposure to patient care or robust evaluation of clinical skills. Many of CACMS newer standardsare focused on achieving social and societal mandates. This is laudable, but if overdone, can distract medial schools from focusing on delivering on their prime mission, ensuring trainees master the principles and practice of Medicine (and of course delivering this care in an equitable manner that respects the diversity of society and the need for social justice). Examiners and accreditors could help reduce stress and enhance quality by simplifying their evaluation with greater weighting on the success of trainees’ progress toward expert status and greater practical evaluation of the degree to which trainees deliver excellent patient-centered care and achieve both patient satisfaction and positive health outcomes. A simplification of accreditation criteria would be a welcome change.

 

In the remainder of the blog I will discuss four questions, with the hope they might spark discussion of how we might improve the training of doctors. 

 

  1. What would the consequences be of combining a modest increase residency positions with a mandated reduction in off-site medical school elective rotations? 
  2. If we explicitly defined a much shorter protected time for preparation for the LMCC and Royal College exams during residency would trainee wellness and clinical experience be enhanced? 
  3. What would the yield be of adopting the rotating internship as a universal first year of residency? 
  4. If we delayed the choice of medical specialization until an internship year, would career satisfaction increase, and would the resulting doctors have greater breadth of expertise?

 

Question 1: What if we began by increasing the number of residency positions in Canada? Medical students and residency training programs rank each other through an on-line system, called CaRMS. Historically, all medical students found a match in a residency program somewhere; albeit perhaps not in their favourite city or specialty. Recently, the number of unmatched Canadian graduates has been increasing, from 11 in 2009 to 68 in 2017. In Ontario the increase in unmatched graduates can be significantly attributed to a reduction in residency slots by 25, in 2016. While 68 unmatched students (out of a national total of 3000) sounds like a small problem; the theoretical threat of unemployment looms large in the mind of medical students. The lack of a match sometimes has tragic consequences, as in the case of Robert Chuwho ended his life after twice failing to match to a residency program. He wrote to then Ontario Health Minister, Dr. Eric Hoskins, “Without a residency position, my degree … is effectively useless. 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”.

 

Franco Rizzuti, president of the Canadian Federation of Medical Students, is quoted as saying thatstudents now apply to an average of 18 programs, nearly double the number reported a decade ago.Still, we should only create more residency positions if we need more doctors. Does Canada need more doctors? Provincial governments tend to believe there are too many doctors (in my view incorrectly).  Data from the Organisation for Economic Cooperation and Development (OECD), show that, in 2011, Canada had just over 2 MDs/1000 population, putting us in the bottom quarter of the pack (Figure below). 

 

patients per 1000

Adding to the scarcity of residency spots for Canadian graduates is an influx of medical students who trained abroad, (international medical graduates, IMGs), many of whom are Canadian citizens. In 2017 there were ~2400 IMGs in the CaRMS match. There are 2967 residency positions available in Canada and 2810 residents in the hunt, per a recent Health Debate article by Dr Karen Palmer. Even excluding IMG applicants, this means there is <2% wiggle room between positions required and positions available. Complicating this too tight supply/demand relationship is the confounder of personal preference (relating to medical student preferences). For example, the is a net efflux of medical students from Quebec, resulting in 58 empty residency slots in that province in 2017; meanwhile these outgoing Quebec students took spots in other provinces. This contributes to a geographic distribution problem. The 1-way valve out of the province reflects a political decision in Quebec to preclude students trained outside Quebec from applying for certain positions in Quebec. An additional problem that exacerbates the shortage of residency positions is that training positions in some specialties are in short supply, relative to demand, (notably dermatology, emergency medicine and plastic surgery-see graph below). If a resident desires a scarce specialty and selects only this option in the CaRMS match they may wind up “unmatched”!

 

First choice discipline

Thus, increasing the number of residency positions in Canada by a modest amount (say ~10%) would have benefits both to trainees (who could match with less stress and travel) and to Canada’s medical work force (which would be right-sized to increase access to care). This is a decision that can only be made by provincial governments.

 

What if we replaced off-site medical school electives with more extended electives and core rotations at a student’s own academic health sciences centre or local community sites? To reduce the risk of being unmatched, it has become common practice that medical students criss-cross Canada performing electives to demonstrate their interest in a given program. They know the 1-2 programs they actually desire but feel compelled to cover their bases by applying broadly. In this auditioning process they serve as their own travel agent and pay for travel, food and accommodations. This process adds to their debt and stress while depriving them of equivalent or better experiences at their own medical school. These brief sojourns do not lead to deep clinical experience (how much first-hand responsibility can one can entrust to a medical student who is only visiting a program for 2 weeks?). A former medical student who was intent on becoming a Dermatologist summarized their experience as follows: "I did 6 electives in dermatology (12 weeks total), and 2 electives in internal medicine... If I was to do it again, I probably wouldn’t have done so many dermatology electives - it’s just that I didn’t get the ones I really wanted until the end. I’m not sure I necessarily needed to do this many dermatology electives in order to match. That being said, I definitely felt the pressure to do the majority of my electives in this specialty to show my interest and build relationships at the programs I was interested in. I did feel they were beneficial in terms of getting to know the programs and whether I was truly interested in the specialty, but I do wish I had felt more freedom to explore other specialties. I found it very stressful to get electives - I often had to apply for the same elective multiple times or to multiple electives within the same time frame to ensure that I ended up with a placement. … I can’t say exactly how much I spent. Certainly, in the thousands of dollars.

 

I propose a “learn local” strategy. If we increased residency spots nationally, while simultaneously discouraging remote electives (having ensured they were unnecessary for a successful CaRMS match), this would reduce expense, travel and stress. Moreover, a shift toward “learn local” would allow them to benefit from extended rotations at their own centres, which would likely foster more meaningful relationships with faculty mentors. Were these first two changes implemented, virtually all qualified medical school graduates would have the realistic expectation of a residency program at the end of medical school. I am not proposing an end to CaRMS; but would advocate for a revision in which the average trainee is interviewing only at their top 5 residency programs.  The current reality is over the top. One medical student told me of her application to surgery programs, which led to the following trans-Canadian interview tour: I am interviewing at University of British Colombia, University of Calgary, University of Alberta, University of Saskatchewan, University of Manitoba, Western University, McMaster University, University of Toronto, Queen’s University, University of Ottawa, Dalhousie University, and Memorial University! Talk about sea to sea! My estimate is that between external auditioning electives and the CaRMS interviews themselves, medical students lose ~4 months of clinical exposure and spend thousands of dollars, for little value. A respected residency program director responding to this assertion noted that if the travelling rotations were ended, residency programs might paradoxically feel compelled to increase CaRMS interviews slot for applicants to allow them to judge the veracity of a student’s interest in their local training program.

 

What if we delayed the choice of career track until after medical school? Some medical students struggle to decide what type of doctor they want to be. Others don’t struggle, although arguably this may be because they are unaware of their options, due to lack of exposure to choices….and there are so many choices! Family Physician, General Internist, Surgeon, Pediatrician, Obstetrician, Oncologist, Radiologist, Ophthalmologist, Pathologist….?  The choice is even harder if one considers the many subtypes of physician (Internal Medicine alone has >14 specialties!). Moreover, for any type of physician, say a nephrologist, there are very discrete role descriptions/promotion tracks (at least in academia). Some nephrologists focus on clinical scholarship and care, others on medical education, others are researchers (clinician scientists), and, more recently, some are focused on quality improvement! This diversity exists for all specialties! With so many options it’s hard to make an informed choice, with life-long implications, after 2 years of relatively superficial exposure to the options.  

 

The experience of a former Queen’s student illustrates the convoluted career decision process faced by medical students. It felt like there was an abrupt change when we went from exploring disciplines in medical school to when we needed to decide on our specialization. In first year, we were required to do observerships to promote variety. But, midway through second year we needed to select our clerkship stream and then all of a sudden it seemed like decisions had to be made. At Queen’s for example, we did one of our core rotations after the CaRMS match, so midway through second year by picking my stream I had to decide that I was not going to pursue Emergency Medicine, Anesthesia or a subspecialty surgery. Also, in order to do most electives, you needed to have completed your core rotation in that area first. So, when choosing your stream you needed to factor in which speciality you wanted to pursue in order to put those core rotations first so you could get the right electives to match to that Residency program." By delaying the choice of specialty until the first year of residency (internship), trainees would likely be making more informed choices. A separate but related benefit is that all doctors would be more broadly trained by virtue of the rotating internship experience. 

 

What if we reinstated the rotating internship? In the bad old days, there was a mechanism for students to sample the smorgasbord of specialties and career tracks before making their choice, namely, the rotating internship. A rotating internship was intended to give doctors a broad expertise and experience so that they could become a general practitioner (GP). We abandoned the rotating internship in favour of a 2-year Family Medicine training regimen in the late 1980s-early 1990s. This change was based on the Kendall report, which advised adoption of a unified 2-year program for training family doctors. Some felt this was good and gave deeper training for family physicians. However, the rotating internship did not just train GPs…it was a venue where many future specialists (like me) cut their teeth. Shouldn’t the public have the expectation that any physician, specialist or family physician, can provide basic life support, manage an airway, place an intravenous catheter and recognize common medical and surgical emergencies? Graduates of a rotating internship learned how to do these things and whether they went on to be GPs or specialists had an intrinsic understanding of the breadth of “big M”, Medicine.

 

Let me tell you my own experience as a medical student and rotating intern. I entered Queen’s medical school in 1977 at age 20, after 2 years of Life Sciences. I was idealistic, energetic and naive. I had a lot of trepidation about the eventual day when I would be responsible for looking after a real patient. Medical school was surprisingly easy for the first 3 years, lots of courses and theory, and patients were in short supply. Then came clinical clerkship, the final year of medical school when one finally began working with patients in the hospital. Donning a short white jacket, like a porter or waiter, my inexperience and lack of status were on full display. I wandered onto the wards and was immediately sobered by the depth and breadth of my ignorance. How could it be that I had not been taught how to place an IV, manage acute asthma, talk to a dying patient? Nonetheless, armed with a pretty good understanding of human anatomy, physiology, pharmacology (and motivated by fear of failure), I began work as a clinical clerk. Mistakes were made and lessons quickly learned. I soon realized I wanted to be the kind of doctor who could handle anything…from cardiac arrests to acute abdomens.  I wasn’t certain what type of doctor this was exactly, so I entered a rotating internship at the Royal Columbian Hospital in New Westminster, British Columbia.

 

 

BC Royal Columbian Hospital

BC Archives image of  the Royal Columbian Hospital from ~ 1978

 

We spent one month on each of the core services of this busy hospital (which had no residents above us-just faculty).  Our rotations covered the gamut from Obstetrics (delivering 100+ babies solo), Pediatrics (sick and premature babies), Surgery (first assist on all operation and primary surgeon for hernias and appendectomies), and Intensive Care (placing art lines and chest tubes and managing ventilators), to Internal Medicine (running the ward and doing all admissions and discharges plus daily rounds). The Royal Columbian was “our hospital”, these were “our patients”. We were scared (at times); but we were proud of our growing knowledge and skill. The hours were long, call every 3rdnight on most rotations and 24 hours on 24 hours off on others. I tell you this not from longing for the old days; but as a matter of fact, and an explanation for how one rapidly accrued procedural expertise and clinical experience. My fellow interns and I were happy. Some became GPs and were in practice within a year; many became specialists, surgeons, anesthetists etc. Through a circuitous route, I went to the University of Minnesota and ultimately became an internist and then a cardiologist.

 

What I learned as a rotating intern has stayed with me and shaped my approach to medicine, an approach that respects the whole person and appreciates the breadth of Medicine. It could be argued that the rotating internship simply delays the herding into silos for one year. I disagree! I had huge frontline responsibilities and the chance (responsibility) to perform unlimited numbers of procedures.  I learned to respect each specialty by walking a mile in their shoes. In my opinion, all physicians should have this broad base of medical training because it makes them more knowledgeable and more comfortable in a breadth of medical scenarios, before they specialize. To truly understand the lifestyle, scope of practice and types of patients a surgeon, gynecologist, psychiatrist or pediatrician typically manages, one need hands on experience. In this pursuit of experiential knowledge, time is not reducible, one has to be an important member of the care team and be present for adequate time to understand the craft of each of these specialties, which in aggregate informs the care for the entire person. The very practical experience acquired in a rotating internship epigenetically alters the medical DNA of a young physician in a way that no clerkship experience can.

 

In his 1978 novel, The House of God, Dr. Samuel Shem (the nom de plume for Dr. Stephen Bergman) fictionalized his experience as an intern at Beth Israel hospital in Boston. The book opens with Dr. Roy G. Baschstarting his internship at The House of God, frightened and anxious, overwhelmed by the responsibility of caring for sick and dying patients (and feeling unprepared by his 4 years at the BMS-Best Medical School). His fellow internsare likewise daunted by the overwhelming challenges of the hospital’s busy internal medicine service. Under the seasoned, guidance of a senior resident, the Fat Man, they learned lessons (the first pulse to check at a cardiac arrest is your own) and eventually managed to run the wards. They learned from attendings and senior residents but mostly they learned (as I did) by being with the patient, as this quote reflects:

 

I make my patients feel like they're still part of life, part of some grand nutty scheme instead of alone with their diseases. With me, they still feel part of the human race. The Fat Man (from The House of God)

 

It is this “being with the patient” one gets form the rotating internship experience.

House of GodSamuel Shem

 

I encourage you to listen to this video of a lecture Dr. Bergman, aka Dr. Shem, gave at the University of Maryland on "Staying Human in Medicine"

 

For a more contemporary trainees perspective on the broadening effect of rotating internships I refer you to a blog by Kieran Quinn, a Queen’s medical student. Doctors that are trained in this manner are arguably optimally positioned to treat the whole person.  They are armed to choose wisely in their testing and referrals because they understand the breadth of diseases and know the type of information various specialists will need in order to make their diagnoses. They tend not to over or under order tests and consultations, unlike the narrowly trained physician. Since we need to limit total time in training I would argue that admission to medical school occur in year 2-3 of University. In addition, the rotating internship could simply be year 1 of a 3-year residency, not an extra year. Let’s bring back to rotating internship!

 

What if we reduced the duration of preparation for the RCPSC exam to 1-2 months? This proposal involves resetting the expectations for how much time a trainee can/should study for the RCPSC exam. While the exam is written in the 3rdyear of residency it takes up much of a resident’s after hours life for the 9 months prior, engendering stress and likely contributing to burnout. To be clear, they are still working as residents while studying; however, exam preparation becomes a large part of their day, monopolizing their time. Trainees should, in my view, be expected to spend no more than ~1-2 months in exam preparation. In the modern era, overpreparation may somewhat be driven by the nature of our trainees, selected based on a track record in undergraduate studies of consistently high marks. These overachievers have no tolerance for the possibility of failing their most important exam.  Objectively however, the success in this exam has long been >95% for graduates of Canadian medical schools. Likewise medical students are allotted 4-6 weeks to prepare for their LMCC exams (which we used to write without preparation). The success rate on these exams is similar to the Royal College exams. On student from a 3-year medical school program told me, We are given 6 weeks of lectures to help prepare us for the LMCC exams but they are optional. This is another month of nonclinical time in medical school. 

 

Examples of success rate for Canadian trained medical graduates writing RCPSC Exams

CMDPG CandidatesMedical Exam

PARO (Professional Association of Residents of Ontario)is the organization representing unionized housestaff in Ontario). In the latest negotiation, PARO residents secured agreement that they would be taken off overnight call for a total of 14 days immediately before each of the 2 parts of the RCPSC exam, with an additional 7 days off between the two parts of the RCPSC exam. While this might have seemed a victory, I would argue it further cements a false view that heroic study is required to pass the exam. While it’s not wise to write an exam while tired, this further time protection, on top of duty hour limits, is straining the ability of residents to accrue experience. So, let’s limit studying to 1 month or some reasonable number and let’s reduce the consequences of failure by offering the exam twice a year. I should add the emphasis on studying for exams is not unique to residency. Let’s recast medical school and residency as programs for adult learners, not an extension of high school, and shorten study reparation expectations for standardized exams!

 

In conclusion: The changes proposed in this blog do not attack the bedrock of medical trainingbut do suggest ways to simplify and refocus medical school and residency training with the goal of producing doctors who are more clinically experienced, less stressed, and less in debt.In aggregate, these proposals would repurpose time that is currently not being well used, is costing students money and engendering stress. My estimate is that the modern medical student spends ~4 months on the CaRMS process (rotations abroad plus interviews) and a month on LMCC preparation.  That’s 5 months of medical school that arguably could be better used.  In residency there is ~9 months of Royal College exam preparation, which also could be reduced without a loss in training depth and arguably with a gain in wellness.

 

The changes proposed in this blog might also allow a more informed career selection decision and broaden the experience base of the average resident.  Reinstating the rotating internship is suggested as one way to ensure our trainees have time to mature and become experienced so that they choose their career wisely and bring to their ultimate practice a breadth that gives them a stable foundation for practice, whatever career they choose.  The training of doctors is a responsibility jointly owned by Universities, Accrediting agencies and Society, writ large. If the collective “we” adopted some of the proposals in this blog we might be able to make changes that reduce the cost and stress of training and produce doctors that are happier and more broadly experienced. 

 

Acknowledgements:While the opinions in the blog are solely my own, I am indebted to the following individuals for their thoughtful critique of this blog: Dr. Tony Sanfilippo, Dr. Leslie Flynn, Dr. David Taylor, Dr. Kathie Doliszny, Dr. John Rudan and Anita Ng. I also thank the students who contributed their assessments and anecdotes of the reality on the ground for today’s medical student.

 

Name
Tony Sanfilippo

Fri, 02/15/2019 - 12:01

Hello Steve,
Your comments, as usual, are insightful and well presented. You've certainly touched on a number of topics that have been troubling the medical education community in this country for some time. A few additional thoughts.
The process for determining the number and distribution of residency training is largely contained within the provincial ministries who fund the positions. Each does it in it's own way, largely driven by available funding, perceived future medical workforce needs (something akin to predicting the weather) and "politics". The requests for input from the medical education community, and the receptiveness to that input, varies with the political leadership of the day and the appointed administrative leadership of the time. Over the past decade, the number of positions available has not expanded. In fact, it's contracted in the face of increasing numbers of applicants from within and outside Canada which, as you point out, has led to the increased competitiveness of the match.
It's been argued by some that residency positions should be openly available based on career intentions of medical school grads and to let the marketplace deal with the issue of needs. That approach has been panned largely because of expense and a governmental sense of responsibility to address perceived deficiencies in certain specialties.
The issue of electives relates directly to the match issue. Students feel they require electives at particular schools to be considered and, although that shouldn't be the case, they are responding to what they're hearing, not only from their peers, but also from faculty who are involved in selection committees.
I think it's also important to recognize that CaRMS itself is often seen as the problem, but I think that's largely unjustified. CaRMS is simply the process and algorithm by which matches are made. It does not determine available positions nor the criteria by which decisions are made, which is still in the hands of functionally independent selection committees. If the system is to improve (which I heartily agree it should), it will require deliberate and unified efforts on the part of the 17 medical schools, and acceptance (or at least compliance) on the part of program selection committees.
I couldn't agree more that the process of transition from UG to PG has evolved in a maladaptive and rather random way and requires major thought and a fresh approach. In fact, the Future of Medical Education in Canada initiatives have supported that need. The potential role of an earlier, graduated selection process or a return to something like the rotating internship would be great starting points for that discussion. The major obstacle to developing solutions has been that there are a great many entities and organizations for whom this issue is critical and would have to be very much involved and agreeable to any solution, including our 17 medical schools, Medical Council, specialty accrediting bodies, provincial and territorial regulators, students and residents. I'm pleased to see that efforts to have such discussions have been and continue to occur, but remain a long way from resolution. Those efforts will certainly be encouraged by interest and thoughtful perspectives from respected leaders like yourself. So, many thanks for your dedication to education and for speaking up.

Tony

Name
Tony Sanfilippo

Name
Paul Armstrong

Fri, 02/15/2019 - 16:20

Steve

Your thought leadership here is most welcome

Speaking from the generational vantage point +1 ahead of you let me agree that

1] we need to shorten the time to enter medicine. Queen's had a 2 year premed program that worked well for many of older docs

2] providing some form of rotating clinical experience that precedes the need to choose a career path resonates well

3] reducing the expenditures & enhancing the logistics  for resident positions [ which should in number align with the #s Canadian medical graduates] in this new information/digital age where we can remote  patents makes good sense

Finally, i would say we should look carefully as to whether the right candidates are being admitted to medicine and teach them early on to tune out to the avalanche of information and focus on what has had and will continue to define medicine as a profession.

Paul

 

Name
Paul Armstrong

Name
Eve Purdy

Sat, 02/16/2019 - 18:50

Dr. Archer,

Thanks for this fascinating read. I love a deep dive and a bit of mental creativity around what might be.

As an anthropologist, I cannot help but see the relevance of a few key theories as they relate to the problems you raise but also in the barriers to solutions.

Cultural compression: This theory suggests that there are times in medical education during which the values and beliefs of the profession weigh most heavily on learners. During moments of cultural compression, those values and beliefs are transmitted and incorporated into the identity of the individual being indoctrinated. The quintessential period of cultural compression is assessment. When we assess people, particularly in a high-stakes setting, we are signalling to them what we think is most important. If we value, as you suggest, physicians that are available/affable/able, then we must really ponder whether current assessment methods – particularly high stakes exams- are in line with those values. If not, then we earnestly risk a cultural transmission towards alternate set of values and beliefs that may not be representative of the kind of doctors we wish to create. I venture that the consequences of this cultural signalling go far beyond the personal wellness of residents for 6-9 months before the exam and wasted time away from the bedside. In my mind, the strong cultural messaging to residents is that knowledge (not availability/affability/ability) is the most important aspect of our job and is the marker of your worth as a physician – and whether we like it or not this value will stick throughout a career. People, who have incorporated that value, then go on to be the next generation of teachers/educators/examiners/medical leaders…and the culture propagates. CaRMS also acts as a consequential moment of cultural compression but I’ll let you explore the cultural signalling of that on your own!

Belonging: The idea that you raise about “learning locally”” just makes so much sense from the perspective of an anthropologist. Humans crave belonging. When they feel that they belong they are more likely to take interpersonal risks (often a necessary step on the path to learning) and they are usually happier. I’ve written about the importance of belonging in medical school before here. The new reality of away rotation after away rotation is not only a threat to the bank account but it also systematically threatens belonging which comes with serious psychologic and educational consequences that we as a community have not only accepted but endorsed and facilitated.

Why is all this (the electives, the matching process, the exams) so hard to change???

Power: There are so many people and organizations with vested interest, and now power, in the process. And so, we end up with the “horse by committee” you presented. The problem is, power is rarely surrendered. Ask any individual from any one of the groups that has power at stake, and I am sure they would agree with some of your suggestions – but not those that relate to reducing their positioning in the process. Each part of your quartet requires stripping power or perceived power from somebody (either almost imperceptibly or overtly) and that is not an easy task…As Dr. S outlines, these changes require consensus from a huge number of stakeholders, all with varying amounts and types power….

I really only offer some anthropologic perspective and don’t offer any solutions, sorry. But I do want to thank you for initiating a conversation which is often a first step on the path to understanding.

Eve

Name
Eve Purdy

Name
Akshay Rajaram

Fri, 03/08/2019 - 21:35

Dr. Archer, thank you for sharing your insights and ideas on this complex topic. I think there are many opportunities for change as you've identified. I offer some of my thoughts below.

1. Increase residency positions - I personally don’t think we need to increase residency positions. As you’ve identified, I think we need to spend more time in medical school exposing students to different specialties and delaying selection of career tracks until the first year of residency (a rotating internship would be ideal). Folded into all of this is convincing more graduates to consider a career in family medicine. Many of my colleagues who have aptitudes and potential for various disciplines were dissuaded from family medicine (“you’re too bright for family medicine”) when their broad base of talents are what the field desperately needs. We need to more actively address this hidden curriculum and promote primary care as a specialty (relationships, information coordination, advocacy).

2. Limit external electives - I believe this is already underway with both internal and external changes. Internally, the UGME is restricting the number of electives that may be undertaken in a single direct entry discipline to increase students’ exposure to different rotations. My understanding is that other schools and the AFMC are taking similar stances. The likely impact of these changes is going to more protectionism, with Queen’s clerks doing more electives at Queen’s in order to ensure that they’re at least competitive at their home school. Folded into this issue is addressing the cost of electives as it contributes significantly to the debt loads of students.

3. In addition to these points, I was struck by your comments about the existence of numerous distractors in medical school and the number of required accreditation standards. Having completed a Master’s in Management and worked for 2.5 years prior to beginning medical school, I’ve noticed a number of inefficiencies over the course of my training. Borrowing a framework from auto manufacturing, Gray Moonen, Dr. Sanfilippo and I co-authored a piece proposing a new approach to undergraduate medical education curriculum review to identify and classify these inefficiencies to assist with addressing them: https://www.mededpublish.org/manuscripts/2019

We welcome your feedback and the comments of other readers.

Name
Akshay Rajaram

Add new comment

The content of this field is kept private and will not be shown publicly.

Plain text

  • No HTML tags allowed.
  • Lines and paragraphs break automatically.
  • Web page addresses and email addresses turn into links automatically.