Helping to improve the CaRMS match

The Canadian Resident Matching Service (CaRMS) process is stressful for Canadian medical students and is a resource burden for family medicine programs. The results of the match are shared annually at the CaRMS forum during the Canadian Conference on Medical Education and are available on the CaRMS website.¹ The mean number of applications by Canadian medical graduates (CMGs) in the 2020 match was 21.6, with one outlier at 113 applications.¹ Concern about those students not matching to the residency of choice is unfounded for most CMGs, particularly for those matching to family medicine. For the first iteration of the match, 81.7% of CMGs matched to one of their top 3 programs, and of those who chose family medicine as their first-choice discipline, 98.4% matched.¹ These outcomes suggest that most students could make 5 to 7 applications and still be successful in being matched to one of their top 3 choices. However, both students and faculties of medicine continue to focus on the small number of students who do not match to their programs of choice, and thus give advice to all students to apply broadly.

My concern with the match, apart from the unnecessary anxiety, is the tremendous waste of resources. This year there were 64 724 applications to all of the family medicine programs by 3172 applicants (international medical graduates and CMGs) for the 1573 positions.¹ This means that 41 applications were processed for each position. Student debt is a continuing concern for undergraduate medicine. MD Management suggests that students should budget $19 499 for residency matching and electives.² Although no Canadian studies exist, anecdotally students report that the costs can be as high as $30 000 for travel and accommodation for electives and interviews. The COVID-19 pandemic has changed this. Students have not been traveling for electives, and the Association of Faculties of Medicine of Canada and medical schools have agreed that all 2021 interviews will be virtual. This change will save many of the costs for students, although I am not certain that it will change their anxiety levels or decrease the number of applications. Other questions remain. Will virtual interviewing persist once the pandemic is under control? Will medical students be expected to “audition” in fourth year by way of electives? I do hope that some changes that reduce student debt will remain.

However, the costs in time and resources for medical programs are not likely to change with COVID-19. During my time as Chair of the Department of Family Medicine at the University of Ottawa in Ontario, our faculty reviewed more than 1000 CMG files (taking about 30 minutes per file), and then set up 4 interview days for 600 candidates, including presentations, refreshments, and interviews by faculty and resident teams. We ranked more than 450 candidates who indicated an interest in our program. In 2019, only 25 CMGs matched to the University of Ottawa in the first iteration, suggesting that more than 400 candidates ranked another program higher. We spent a great deal of time trying to gauge whether each applicant was genuinely interested in our program. Although the family medicine program matching was better in 2020, the resource issues continued. Programs are concerned that virtual interviews will not give the students a good idea of what the program has to offer and will thus affect recruitment. At the same time, resources will continue to be a concern for virtual interviews if the heavy burden of applicants continues.

The message for students to apply broadly is misleading for those wishing to pursue family medicine; 99.1% of CMGs who wanted to pursue family medicine were successfully matched. The advice to students to apply broadly might be applicable for those programs that fill in the first iteration and to some specialty programs, but this counseling is incomplete. Students should know the future job prospects of their discipline of choice. The Canadian Post-MD Education Registry report on physician opportunities in Canada in August 2017 showed a favourable ratio of positions available to exiting postgraduate students for family medicine.³ For the 2043 available opportunities in family medicine there were 1417 trainees entering the work force. In contrast, there were 1358 graduates for 1131 positions in other specialties; 501 graduates for 204 positions in surgical specialties; and 74 graduates for 63 positions in laboratory medicine.³ The number of posted positions in this report does not include locum or part-time positions or postings prior to March 2017. Regardless, the message is clear: job opportunities are more plentiful in family medicine compared with other disciplines.

Our family medicine programs play a role in generating the large number of applications. Many programs require separate applications for the various sites in the program. Thus, students might have multiple applications for a particular program. As most students will get one of their top 3 to 5 choices, the excessive number of applications does not warrant the approach we are taking. Ontario family medicine programs addressed the large number of international medical graduate applications through a collaborative approach that centralizes the review and interview stages. This streamlines the process for both programs and applicants.

I approached a leader of the Canadian Federation of Medical Students in 2018 seeking support to challenge the current Canadian resident matching system. Sadly, I was met with acceptance of the status quo. Students feel vulnerable in the application process and accept the costs and challenges, focusing on the risk (although small) of not matching to their residency program of choice. During the CaRMS review at the Canadian Conference on Medical Education each year I have heard at least one student admit to not needing to apply to so many programs once he or she had been matched.

The goal of family medicine programs is to ensure a successful residency for our learners, and thus a good fit is important. I believe we should be proud of our training programs in family medicine in Canada and that well-matched students will succeed in any program. Trainees who are not matched appropriately either to the place or program that best suits their needs will be less successful. It might be more important that they are close to family and other supports than being matched to a program that provides a specific approach. I am not suggesting the match be discontinued, only that we reduce the anxiety of the applicants by using evidence to convince our learners and programs that applying to 7 programs—at most—will ensure a good match for most students.

I think we still have much work to do to ensure that our resources are used efficiently and effectively to support our students in making a good match. I look forward to suggestions on how we, collectively, can reduce this challenge for our future colleagues.

• Copyright© the College of Family Physicians of Canada