Code blue: finding room to groom new doctors

By LISA PRIEST

Friday, September 30, 2005 Posted at 9:01 AM EDT

Keen to become an emergency-room doctor, Nick Rose knew that with only
27 residency spots available across Canada, he faced fierce
competition. To boost his chances, he travelled the country doing
unpaid work in five hospitals, hoping to impress.

To keep costs down, the Ottawa medical student slept in gritty youth
hostels and boarding houses, and crashed on the couches of people he
barely knew. He spent $4,500 on airplane flights and food. But his
efforts paid off: He obtained exceptional recommendations from senior
emergency physicians and academics.

Without those letters, Dr. Rose, who also has a doctorate in
bio-organic chemistry, had little chance of making it into the
five-year specialty of emergency medicine. With them, he was able to
compete against 58 others who also made it their first choice for
residency training, which doctors must complete before they are
licensed to practise.

"Residency in emergency medicine has become more competitive in the
last few years," said Dr. Rose, 32, who landed an emergency medicine
residency at Vancouver General Hospital.

"You can blame ER [the TV show] for that."

At a time when Canada faces a shortage of most types of doctors, and
patients face lengthy waits for treatment, many wonder why there are
not more training spots.

Even though medical-school enrolment has been expanded, there will not
be enough doctors to replace those who are retiring, said Ruth
Collins-Nakai, president of the Canadian Medical Association.

"In the next two years, there are 3,800 physicians expected to retire.
About a quarter to a third are expected to reduce their hours," Dr.
Collins-Nakai said. "That tells us that we're probably not producing
enough students to replace those retiring, let alone fill the gap."

Provincial governments, with the help of medical schools, determine the
number of residencies for medical graduates.

But planning has been imperfect and shortages have occurred.
Consequently, "not only are we stealing [doctors] from province to
province," the Edmonton cardiologist said, "but we are poaching from
countries that can ill afford to lose their health human resources."

For medical-school graduates, the small number of Canadian residencies
-- about 1,508 spots -- means competition is intense, especially in the
more coveted fields of emergency medicine, ophthalmology, ear, nose and
throat (ENT), plastic surgery, and dermatology.

Provincial governments finance residency positions. This year, there
were 107 residencies for every 100 medical graduates, but only a small
number of spots for the more sought-after specialties.

Specifically, there were only six spots in dermatology, 49 in
diagnostic radiology and 18 in ear, nose and throat. In contrast,
family medicine had 578 spots.

What Dr. Rose did to earn his emergency-medicine residency is not seen
as remarkable, but merely what is required.

Ben Hoyt, president of the Canadian Association of Interns and
Residents, said the 12 weeks during medical school in which students
try specialties of their choosing used to be about rounding out an
education.

But now, "all you're doing is pimping yourself to these people so that
you'll get a good reference and maybe be picked by their program," Dr.
Hoyt said. "You don't learn much and you definitely don't round out
your education and you're paying for flights coast to coast. It's not a
good system."

Every year, every graduating medical student in Canada must rank the
specialties they want and the location where they wish to train. After
that, training-program heads rank the students, relying heavily on
interviews, letters of recommendation, and the students' written
explanations of their choices. Then the list of students is matched up
with the institutions looking to fill their residencies.

The most desired specialty spots are filled quickly. Then those who did
not get what they wanted, as well as international medical graduates
and Canadian medical graduates from the year before, compete for what
is left.

After both rounds last spring, 16 family-medicine training positions
sat vacant, as did two spots in laboratory medicine and one spot in
each specialty of orthopedic surgery, neurosurgery, and psychiatry,
according to Canadian Resident Matching Service figures.

Medical students keen to lead balanced lives and avoid the workaholic
ways of previous generations of doctors are seeking the so-called
"lifestyle specialties" of ENT, urology, radiology, dermatology, and
ophthalmology.

It is a trend policy makers probably did not anticipate roughly a dozen
years ago when they began slashing medical-school enrolments in the
belief Canada had too many doctors.

Cutbacks also took place as the population was aging and using the
health-care system more. As well, a growing number of physicians are
women, who, on average, work fewer hours than their male counterparts.
The number of foreign doctors entering Canada has declined, and
physicians have been steadily retiring.

Sarita Verma, board chairwoman of the Canadian Resident Matching
Service, said the number of specialty and family medicine spots should
be increased.

"If the numbers of residencies aren't increased, we can't train them
[additional doctors]," said Dr. Verma, associate dean of University of
Toronto's postgraduate medical education.

Many, including Dr. Verma, are recommending a ratio of 120 residency
positions for every 100 graduates. If that had been the case this year,
it would have meant 178 more spots in addition to the 1,508
residencies.

A federally funded task-force report said as many as 4,000
international medical graduates could be eligible for residencies if
they were available.

"We know there are people who passed qualifying exams in Canada who
can't get residency spots," said Hugh Scully, spokesman for Task Force
Two, which prepared the report.

The problem of too few residencies is also having a ripple effect on
the subspecialties, which require further training after a doctor has
completed specialty training.

At least 20 programs, most of them subspecialties, in 10 medical
schools sit empty. The Royal College of Physicians and Surgeons of
Canada, the body that accredits them, has deemed them "inactive"
because not one doctor is in them.

Pediatric subspecialty programs in childhood kidney disease, cancer,
diseases of the endocrine system and infectious diseases are without
pediatricians, because of lack of interest and, in some cases, lack of
funds. Also, programs in geriatrics, adult rheumatology, pathology,
vascular surgery, adult hematology (the specialty of blood diseases)
and maternal-fetal medicine (the study of high-risk and problem
pregnancies) sit empty.

In Vancouver, Dr. Rose is pleased to have made it into the high-paced
life of emergency medicine.

"It's so competitive," he said of the quest to get a specialty spot,
that "unless you decide to do family medicine [where there are lots of
spots], there are no guarantees."

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