Stephanie ChanStephanie Chan is a PGY-2 in Internal Medicine at Queen’s University and Kingston Health Sciences Centre in Ontario

David Taylor

David Taylor is the Core Internal Medicine Program Director at Queen’s University and Kingston Health Sciences Centre in Ontario.

For Canadian medical students applying to postgraduate medical education programs, the selection process can feel like a game – one with high stakes, ambiguous rules, and where outcomes often seem like they are based on luck. This has led to the common concern that “the system is broken”. Proposals to address this current state range from simply increasing the number of residency positions, to limiting student electives, to implementing best practice guidelines for the selection process. Yet, despite substantial debate on these ideas of how to improve the Canadian  residency selection process (and some action taken), students and training programs report a lack of impactful change. Perhaps, rather than tinker with the selection process itself, it’s time we start looking for the upstream causes of our current problems.

Medical students feel immense pressure to match. This, coupled with a declining seat-to-applicant ratio over the past several years (from 1.13 seats per applicant in 2009 to 1.03 seats per applicant in 2019), means most medical students “parallel plan” – a strategy that involves submitting applications to several specialties, even ones in which they are not particularly interested – to maximize their chances of matching. While this strategy provides some reassurance to students, it is costly from a financial and labour perspective for both students and postgraduate programs. In 2020 applicants indicated interest in an average of 21.6 programs. Students must pay $31 for each additional program over the nine included in the $303 match participation fee, which translates to an average cost of $693.60 per application. Each program requires that the student write a unique personal letter, which adds substantially to the burdens imposed by busy student clerkships.

Postgraduate programs are, as a result, inundated with applications. Program leads face a challenge in trying to elucidate which applicants are truly interested in their programs – especially those in specialities like internal medicine and family medicine, which are commonly used for parallel planning. For example, 6,846 internal medicine applications were submitted in 2020 from 891 applicants, but only 453 applicants ranked internal medicine as their first-choice discipline. In our own internal medicine program, this required an estimated $100,000 in faculty time, 50 to 55 resident work days, and four weeks of program administrator time in a convoluted and poorly understood process of interpreting personal letters, student elective profiles and letters of reference.

Difficulty in determining applicants’ genuine interest in a program inevitably results in the selection of many interviewees for whom the program is not their specialty of choice. This has two obvious consequences:

  1. Not all “specialty of choice” applicants will have a chance to be interviewed, that is, qualified applicants may not be granted interviews at their preferred program if their strengths go unrecognized during file review.
  2. Postgraduate programs risk having unfilled spots if much of their rank list consists of parallel planning applicants.

Thus, applicants submitting more applications due to fears of not matching may paradoxically reduce their chance of getting the residency spot of their choice. In other words, the chances of a mismatch are greater with rising application volumes.

The COVID-19 pandemic has increased CaRMS application anxiety, which may continue the annual upward trend in application numbers in the future match. We are in urgent need of thoughtful solutions that protect students, schools and postgraduate interests.

We suggest a new approach that involves a smaller first iteration of the match with limits on the number of applications per student, followed immediately by a larger second iteration. Further, similar to the model used in the United States, we suggest that both of these iterations have a common date for releasing results (i.e. match day), in order to eliminate stigma of matching in the second round. Although this will limit applications to multiple specialities, it would allow applicants to safely reveal and act on their true preferences as they may feel less pressure to apply to specialties in which they have little interest but to which they were advised to apply. Moreover, specialties that frequently receive many “parallel plan” applications – such as internal medicine and family medicine – will be better placed to selectively interview those with a true interest in their specialties.

The concern of increasing numbers of unmatched applicants requires longer term strategies as well, as outlined by the Association of Faculties of Medicine of Canada in 2017, which may include options such as increasing the number of postgraduate positions, increasing transparency in the postgraduate selection process and increasing opportunity for transfers. However, despite submitting over 20 applications on average, 81.7% of Canadian applicants had matched to one of their top three program choices, with 92.1% matching to their 6th choice or above, suggesting that most Canadian medical graduates do well. However, limiting the choice number of choices in the first round may be a good way to improve the rate at which students match to their specialty of choice.