What is a “fellow”? Stages in the career of physicians (American summary but is similar to the situation in Canada) (source)
The following case of a patient with unstable angina has an unexpected backstory, one unknown to most patients and even to many physicians. The backstory highlights a deficiency and vulnerability in Canada’s medical training system for specialist physicians.
A middle age patient presents with multiple risk factors for coronary disease, including hyperlipidemia and type 2 diabetes mellitus. He has classical angina with chest pressure on exertion, worse after eating a meal. He was investigated and felt to have coronary artery disease. Consequently, he underwent angiography and was found to have a very tight narrowing in his proximal left anterior descending coronary artery (LAD) (image). This type of narrowing is called the widow maker lesion because, being near the origin of one of the heart’s 3 major blood vessels, it serves a very large part of the heart muscle. Should the LAD artery close at this point, so near its origin, it usually leads to a large heart attack, which may be fatal. The doctor in the angiography suite was an interventional cardiologist. An interventional cardiologist is a doctor who has trained for 2 years as a “fellow”, after completing internal medicine and cardiology residencies (see lead image in this article). This specialist put a guidewire across the narrowing in the LAD artery and inflated a balloon-mounted stent. The coronary angioplasty reduced the narrowing from over 90% to 0%. The patient’s symptoms disappeared and he continued to do well when seen in follow-up several weeks later.
LAD stenosis pre-angioplasty: showing a widow maker lesion (the tight narrowing in the dye column near the beginning of the LAD artery-just beyond the tip of the catheter)
LAD Post-angioplasty: showing the results of a successful angioplasty performed by a fellowship-trained interventional cardiologist
Sounds like great care, so what is blog worthy about this case? Simply this: Canada does not have a system to fund the training of fellows of any type-including interventional cardiologists! For many essential types of specialist practitioners there is also not clear certification by the traditional regulatory agencies (Royal College of Physicians and Surgeons of Canada(RCPSC) and the College of Family Physicians of Canada(CFPC). In brief, Canada has neither a funding mechanism nor a regulatory mechanism to support the training of the most highly trained subspecialists in our health care system!
To give further examples, we also lack funding mechanisms for the training of the cardiologists who perform echocardiography, electrophysiology (heart rhythm problems), or specialize in heart failure management (which is the #1 cause of hospital admissions in Canada). I use the example of these 4 subspeciality fellowships* in Cardiology because I am familiar with them, being a cardiologist myself. Back when I trained there were few fellowships because the fields were not as advanced. I trained as a cardiologis and learned echocardiography, coronary angiography, electrophysiology, and heart failure management (and rode my dinosaur to work). As knowledge advanced and our ability to improve human health progressed, we have come to need doctors who are super experts in narrower but deeper disciplines. Just think of the advances that require special expertise (the stuff the fellows must master after qualifying as a general cardiologist): for the interventionalist (angioplasty, percutaneous valve replacement (TAVR), percutaneous mitral valve repair, and percutaneous closure of atrial septal defects), for the echocardiographer (transesopahgeal echocardiography, coronary CT angiography, cardiac MRI), for the electrophysiologist (3-D cardiac electrical mapping, ablation of atrial fibrillation, placement of implantable defibrillators and bi-ventricular pacemaker) and for the heart failure specialist (management of implantable hearts, such as left ventricular assist devices and assessment of cardiac genetics). These things simply did not exist in the old days (i.e. pre 1985). However, neither the funding nor certification of the fellowship programs required to create these specialized advanced learners did not keep pace with medical advances and societal expectations. We relied heavily on ad hoc funding, often from industry, to pay fellows, and those days are over. This lack of funding for fellowship training programs is pervasive, affecting all types of Medicine (from surgical disciplines through, medicine, pediatrics, obstetrics, radiology, anesthesia, etc.).
Even when we create funding for fellowships, which is done center by centre, program by program, our regulatory bodies, the RCPSC and CFPC, do not actually certify/accredit most fellowships. For a few fellowships they do offer accreditation and evaluation in the form of recognizing the program as an Area of Focused Competence (AFC) or Diploma programsbut in my view this is inadequate both in depth and breadth.
If this is getting confusing for nonmedical folks, let me make a brief diversion and outline the life cycle of a doctor. After medical school, doctors must complete several additional years of practical training before being eligible for licensure and independent practice. This training period, usually 2 years for family medicine (regulated by CFPC) and 5 years for other specialties (regulated by the RCPSC), is referred to as a residency. The funding for these trainees originates from the provincial ministries of health and flows through the academic medical centers to the hospital and then the trainee. The government’s funding gives them regulatory control of the number of residents trained, providing the opportunity for human resources planning to meet societal needs, and ensures stable funding of the residents. However, after residency many doctors further specialize and chose to enter fellowships.
These specialists and subspecialists serve absolutely critical functions in modern medicine and their roles cannot be replaced by generalists. In the Department of Medicine which I lead, for example, there are 14 specialties ranging from Allergy to Rheumatology (click here).
An illustration of the diversity of types of doctors in the Department of Medicine at Queen’s. Faculty members within each of these Divisions have completed a residency program (as a minimum). Most have completed two residency programs and many have also completed a fellowship program.
The entry level for our faculty is completion of a residency program, which is funded systematically and accredited by the RCPSC. However within each specialty (like Cardiology) there are subspecialities which require fellowship training (like our interventional cardiology example). A clinical fellowship is an opportunity for a physician to obtain advanced training and/or to acquire more specialized expertise not normally acquired during residency training. Fellowship training is ordinarily between 1 and 3 years in duration. As an educational experience which does not lead to certification by the RCPSC or the CFPC, a clinical fellowship on its own is not a pathway to permanent practice as a specialist or family physician in Ontario.
As for regulation and recognition: the RCPSC recognizes a few Areas of Focused Competence (AFC) or Diploma programs (see table below, click here); however, even the AFC programs are not provincially funded and these few offerings do not comprehensively reflect the breadth of society’s needs. Here is a link to our fellowship programs at Queen’s (click here). You can see our list is modest compared to McGill (click here) or the University of Toronto, which has fellows from 63 nations (click here).
So where does Canada get its specialists? They come from 6 sources.
1) An ad hoc network of fellowships based at academic medical centers (tertiary care hospitals affiliated with Universities). These centers provide excellent fellowship training programs; however they are uncoordinated one to another and each relies on ad hoc funding mechanisms. The means by which academic medical centers fund fellowship positions includes arrangements in which the fellows themselves “moonlight” as physicians and use their billings to pay themselves. This only works with fellows who are eligible for independent practice in Canada and, if excessive, can compromise the educational component of the fellowship. Alternatively, some fellowship positions are supported by creative billing opportunities (e.g. surgical fellows billing assistant fees in the operating room). This option is not available to most nonsurgical specialities.
2) In addition, some fellowships may be supported by unrestricted grants/donations from Pharma and device companies. Pharma and device company funding raises questions of conflict of interest. One has to rigorously uncouple purchasing devices and prescribing drugs from the funding of fellowships (and this is not always possible). This source of funding used to be common but has largely dried up due to new Pharma’s regulations on dispersing such funds (see 2020 Innovative Medicines Canada revised Code of Ethical Practices).
3) Some fellowships are funded by philanthropy by donors or by Departments, comprised of academic physicians. These dollars are scarce.
4) Many trainees receive fellowship training in the United States. In Canada, we have had the great luxury of an historically close relationship with the USA. Many Canadians, including me, went to the United States for fellowship training. We provided America with clinical, research and educational service and in return we received great training. There are many more established fellowships in the USA than in Canada. Hospitals and Departments at American academic medical centers fund fellowships not because of altruism but because of the important service these fellows provide in support of clinical care, research and education. However, with political changes in America, COVID-19 challenges and budget cutting in healthcare funding for American academic medical centers, access to US fellowships are less accessible than in the past.
In Canada ~25% of all specialists did their undergraduate medical education (medical school) and/or additional training in another country. This over-reliance of international medical talent for a core function of our health care system is (in my opinion) reflective of Canada failing to train doctors in adequate numbers to meet the country’s needs. This deficiency is most evident in the lack of a mechanism to train Canadian doctors through a robust portfolio of fellowship programs.
5) Fifth, international medical graduates may come to Canada and bring with them funding from their home government. Most of these sponsored fellows have return of service expectations from their home government and cannot remain in Canada post fellowship. The largest source of sponsored Visa trainees come from Saudi Arabia. While these trainees provide excellent service during their training, the vast majority return home after training and do not remain in the Canadian medical system in the long-term.
6) A 6th route bypasses fellowship training altogether and simply recruits specialists who have already completed training in their home country. This is an interesting route of entry to Canada. In some case it brings international excellence; however, in many cases it is challenging to asses an international specialists skills and credentials. Moreover, hiring specialists from other countries deprives these countries of much needed specialists. This bypass mechanism for acquiring specialists process also lulls Canada into believing it doesn’t need to fund fellowship training programs for Canadian residents and citizens.
It is noteworthy that few in Canada, other than the payers (the provincial governments) believe that we have too many physicians. Canada has 2.7 physicians per 1,000 population (including residents) compared to the Organization for Economic Co-operation and Development (OECD) average of 3.5 per 1,000 population (2017 or nearest year) (see graph below).
Canada has 86,092 physicians and ~ 1/4 obtained their MDs outside of Canada (see graph below)!
International medical graduates (IMGs) account for ~25% of all Canadian specialists (although some of these doctors did part of their training in Canada and not all these doctors are in fellowships, click here). The vast majority of IMGs pursue studies in the medical specialities (57% in 2017) with the largest group within the medical specialities in 2017 being Internal Medicine (220) and Psychiatry (205). Thus, Canada is clearly relying on IMGs and other countries to meet our need for fellowship training to generate a home grown batch of specialists.
Bottom line: The lack of a systematic approach to funding and credentialling fellowship programs, reflects a failure of vision and lack of comprehension and collaboration between the multiple stakeholder organizations, which include: Provincial ministries of health, the RCPSC and CFPC, Canada’s Deans represented via the Association of Faculties of Medicine of Canada, AFMC, and the federal ministry of health. There is also a complacency in Canada’s medical education community. The PGME deans should be advocating for a robust fellowship funding and credentialling mechanisms.
Canada requires a steady supply of highly trained specialists but currently we neither pay for their training nor provide RCPSC or CFPC oversight of the training (in many cases). To ensure a stable supply of doctors with Canadian training we need to urge the Provincial governments, the Deans of Canadian Medical schools (AFMC), PGME Deans and the CFPC and RCPSC to work together to extend the same standards for funding and certification enjoyed by our well-respected residency programs to include fellowships.
As I have previously blogged (click here), Canada needs to pay for its own medical education programs, including fellowships.
I look forward to your comments.
*What’s in a name: There is some wobble in the terminology: When visa trainees come for subspecialty training from outside Canada and do not have the base specialty Royal College training, they are also referred to as “Fellows”, even though they are essentially doing a residency program. Also, Subspecialty Program Directors and Faculty may refer to their residents as “Fellows”, because they have completed their base specialty residency, even though from the RCPSC perspective, subspecialty trainees in accredited programs are considered to be residents.