Choosing the right resident

I recently spent hours scrutinizing and trying to objectively rate CaRMS applicant dossiers as a member of our residency training committee. Then I shared and sorted my impressions among those of my five other committee colleagues and sat together a dozen hours the last Saturday of January interviewing and reviewing our short-listed candidates. It’s brutal. For us and for the candidates. And it’s unimaginably more bru­tal for those who didn’t get an interview who must recognize the finality of a career door closing.

We on the committee are uncomfortably aware of how important and life changing the application process is for each candidate. We in turn want to use the best, fairest, most inclusive method of choosing the right resident. 

Our selection process starts with a scor­ed objective dossier evaluation and ends with structured interviews created by an industrial psychologist who designed the template of questions to tease out qualities we feel are important in our field. It flirts with “objectivity” in an otherwise sub­jective ges­talt evaluation. 

We have a record of selecting good residents in our field, but I’m not sure the process allows us to do the best job. 

The national fourth-year CaRMS match was mandated in 1993. In my opinion, the old way had definite ad­van­tages. Applicants could be more mature in their exposure to specialties to make real choices. They could apply any year after graduation and more than once if need be. Letters of reference were more meaningful to committees as applicants usually participat­ed at a higher, more critically ob­servable level. 

If they didn’t match to a desired residency, their rotating internship allowed them to get a general licence to do locums or open a practice. At the end of medical school and internship, they were relatively well-rounded, fully trained general doctors with doors open to most op­tions of practice or training.

There are problems with requiring medical students to apply for their one chance at a residency in the midst of their final year. 

First, they spend much less time and energy in their fourth year actually learning to be a doctor. In competitive specialties they are doing “audition” electives all over the country, flying week to week to put their faces in the minds of selection committee members in as many schools as possible, positioning themselves for good letters of reference, and becoming proficient in only one small part of medicine. 

Some do five or six electives in the same specialty. If the residency they want is in a highly competitive field, they must also do electives and get letters for a backup specialty. Then, if they are lucky, they spend January of their fourth year again blowing their carbon credits to fly all over the country to do interviews. It’s a huge commitment. 

The experiences and breadth of knowledge they give up during a critical time of medical education must detract from their ability to become the best doctor they can be. The prequel is that in order to get those desired electives lined up in the fall of fourth year, they have to guess what specialties into which they want to “book” by early third year. 

How realistic is it to think that students with 2 years of mostly nonclinical medical school under their belt really know what they want to do for the rest of their career? How will they otherwise get exposed to the fields they neglect in order to concentrate on one or two specialties? How do we know if we want to train them? 

Every year our applicant pool unveils a number of students who have had what we call “a late epiphany.” They did what they thought might be a throwaway elective late in October of final year, and fall in love with that specialty. They are at a decided disadvantage in the application process as all of their letters, research projects, and previous leanings are what show up on their CaRMS dossier. 

We still take these candidates very seriously, but they have to be especially good to rise to the top. And what about the great candidates who don’t make a match to their beloved field in that particular year just because there was one slightly more competitive candidate? They really can’t ever reapply to the main match. And if they choose not to match at all, they can’t even work as a physician. 

If they match to a program that was a distant second or third place backup, how great will they be for that specialty? Most brutally, there are some amazing candidates who come this close to matching into a highly competitive residency who have put too many of their CaRMS eggs into one basket and don’t match at all. They are hooped.

From the perspective of a residency selection committee member, and from what I hear from the medical students we train, I don’t see the advantages of the currently required residency match out of fourth year. 

There are people smarter than I am who are in charge of evaluating these things, but I think the short- and long-term consequences are not especially fav­orable: to an individual’s undergraduate medical education, to the student’s ability to try a few specialties on for size before committing to a match, and to a specialty’s ability to consistently pick the best candidates. The finality of the one-match one-chance decision is also troubling because only if the stars are perfectly aligned can post-CaRMS changes be made. 

It seems to me that the option of the rotating internship should be ob­jectively and seriously re-evaluated. Rotating internships contribute significantly and positively to the practice of medicine, confidence, maturity, exposure to new medical fields or concepts, cementing of specialty preferences, and development of close lifelong relationships with colleagues in unrelated fields. For me it was a formative, necessary year.

Medicine has changed in the last two decades, including how specialists and family medicine-trained practitioners practise. We should re-evaluate this forced early differentiation into specialties. 

There still may be some students who choose to match to a specialty right out of medical school. But perhaps we should revive the option of applying to a 1-year rotating internship match without prejudicing the student from later entering the specialty or family medicine CaRMS match. 

It wouldn’t surprise me to see some specialty programs openly state a preference for trainees with a rotating internship. I see many students being more prepared to commit to a specialty they know they really want or would be good at, and would be more able to demonstrate to selection committees that they are the best candidates. 

And last but not least, they would spend the last undergraduate year in medicine, actually learning medicine. 
—CV