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Mission impossible

Well, our final year students have just submitted their applications for residency matching this year. They have undertaken the Herculean feat of trying to figure out which of 30 different types of doctors they want to become. This includes family medicine and 29 other specialties. Really? 29?I can't even imagine as a first year medical student who is just glad to have made it into medical school after years of work, to be told that now I have 30 different options to consider. How would a medical student even know what some of the specialties are? Unless a specialty has been the focus of a TV series such as ER, it is an impossible task.Back in the day, (I know, here I go again…) the rotating internship gave us much more time to try to figure out who we wanted to be when we grew up. We had more opportunities to get exposure to various disciplines and find role models to emulate. Because let's face it: Role models are a crucial factor in decision-making.

Don't get me wrong, we are not going back to the rotating internship. That has been a very clear message from our provincial governments who fund residency education. The way we structure residency education must not increase the length of training. This is very understandable in the midst of the current financial constraints on our government. But this does mean we are asking students to make decisions much earlier than ever before.

The other aspect that never occurred to us is that we could be faced with under or unemployed specialists. The workforce aspect is also important as trainees have to think about the employment opportunities when considering a preferred specialty and practice location. How could a medical student know what to expect potentially 7 to 9 years before completing residency?

Now let's look at this with an education lens. Medical schools have a very clear social accountability mandate, and according to accreditation standards they must produce graduates who are competent to enter any residency program. Some people call this the pluripotent physician.

How can a medical school enable enough exposure to 30 different specialties to assist students in their decision-making? Clerkship just isn't that long. As per their mandate, medical schools focus core clerkship activities around general areas or generalist specialties. These currently include family medicine, internal medicine, pediatrics, general surgery, obstetrics and gynecology, psychiatry, emergency medicine, anesthesiology, and often in a more longitudinal manner, ophthalmology, ENT, imaging and laboratory medicine. 

At most schools that takes a full year. For schools with a four-year program, several weeks are dedicated to elective time, to enable students to experience a diversity of disciplines and round out their education. However, more and more, students who are considering a career in what is perceived as a competitive specialty end up spending almost their entire year focussed on doing electives in that one specialty. This completely negates the original purpose of electives and the final phase of MD education.

So how did we get to this point where our students have this impossible task before them? When one looks at the current 30 choices on the menu for students, it is not clear how we got there. Why are several surgical and laboratory specialties considered entry routes while internal medicine, pediatrics and psychiatry specialties are not?

A recent survey of students has identified that over 70% of students do not consider that they have had exposure to all entry routes and are very concerned about their ability to match into their specialty of choice. In our current environment of decreased flexibility related to fewer residency positions and challenges in residency transfers, should we not be enabling students to have fewer choices to make initially, and then offer opportunities to further focus their training during residency?

As far as I am concerned, this is Mission Impossible. 

Geneviève Moineau, MD, FRCPC