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VOL 52: JUNE • JUIN 2006 Canadian Family PhysicianLe Médecin de famille canadien

805

Collège College

Where have all the residents gone?

Part 1: Putting the declining family medicine match rates into context

Rashaad Bhyat,

MD

I

nterest in family medicine is in decline.1,2 This trend has emerged clearly in the literature and the mass media. This article aims not only to assess the situ- ation but to stimulate a discussion of how to encour- age medical students and young Canadians to pursue a career in family medicine in this new climate.

Decreasing numbers of Canadian medical school graduates are selecting family medicine in the resident match. The 2005 Canadian Resident Match Service data show that 27.6% of new graduates are choosing family medicine. While this fi gure increased slightly over the year before, it has slipped steadily from 1992 (44%) to 2002 (29.6%) to the present.1

Diminishing enthusiasm for family medicine mani- fests early in medical school. A study by Wright and colleagues at 3 Canadian medical schools showed that only 20% of new medical students were considering family medicine as their fi rst career choice.3 Many fac- tors explain this low level of interest, including medical students’ concerns about low prestige, low income, and the breadth of knowledge required for family medicine.4 Heavy family physician workloads also contribute to stu- dents’ avoiding the discipline.

The current family physician shortage will worsen in the coming years as physicians of the baby boomer gen- eration scale back their work hours before retirement.

The problem is further compounded by 3 factors: short- sighted government planning, lowering medical school enrolment in the early 1990s and reducing the pool of potential family medicine residents; bureaucratic reluc- tance to repatriate Canadians studying medicine abroad;

and the unwillingness of some new family physicians to work the long hours of their retiring peers, owing to family and lifestyle concerns.

The cost of postgraduate education in Canada has increased rapidly over the last 15 years, outpacing the rate of infl ation. Deregulated fees in some provinces, notably Ontario, have dra- matically affected medical

education. The national average for medical school fees was $10 349 in 2005-2006, an increase of 59% from 2000- 2001.5 Medical school tuition is only part of the fi nancial equation in physician training. Undergraduate tuition fees averaged $4214 for the 2005-2006 school year, a 22% increase from 2000-2001.5 During the same period, however, student fi nancial aid did not increase to the same degree. This has resulted in record levels of stu- dent debt and reduced accessibility to medical education for students from middle- and low-income families.

The debt issue is troubling. The 2004 National Physician Survey found that, by completion of medical school, nearly half of Ontario medical students expect debt loads in excess of $80 000.6,7 Family medicine is often less fi nancially rewarding than specialty medicine.

In this new climate of overwhelming debt loads, it is dif- fi cult to convince students to choose a career that will exacerbate their fi nancial stress.

Indeed, Duffi n notes that a fi nancial barrier to medi- cal school now impedes many students well before the application stage.8 If you cannot afford an under- graduate degree, how can you contemplate fi nancing 4 more years of medical school? The financial bar- rier is already affecting medical school demographics.

At Ontario medical schools, Kwong and colleagues9 found that, as tuition rose from 1997 to 2000, the pro- portion of medical students from lower-income fami- lies decreased.The socioeconomic profi le of medical graduates has become increasingly skewed toward the upper echelons and does not refl ect the broader Canadian population. Our future physicians could eas- ily have great diffi culties in understanding the reali- ties of low-income patients.10 It does not bode well for family medicine. Medical students from lower socio- economic backgrounds, if they have somehow overcome the obstacles and made it into medical school, are more likely to select family medicine.1

continued on page 807 Common Journal: Trim; 3.5” x 1”

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Residents’ Page

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VOL 52: JUNE • JUIN 2006 Canadian Family PhysicianLe Médecin de famille canadien

807

Collège College

Students rejecting family medicine are often con- cerned about lower income as practitioners.1

These concerns are becoming more acute in the cur- rent environment of high tuition and heavy debt loads.

In this context, renewing enthusiasm for family medi- cine will be challenging but not impossible. This issue will be addressed in the next article in this 2-part series, which discusses specific strategies to foster more inter- est in our discipline.

Stay tuned to next month’s Residents’ Page for,

“Where have all the residents gone? Part 2: Renewing interest in family medicine.”

Dr Bhyat is a second-year family medicine resident at Memorial University in St John’s, Nfld.

References

1. Canadian Resident Matching Service. Proportion of Canadian graduates choos- ing family medicine by medical school 2005 match first iteration. Ottawa, Ont:

Canadian Resident Matching Service; 2005. Available from: http://www.

carms.ca/jsp/main.jsp?path=../content/statistics/report/

re_2005#table111. Accessed 2006 May 2.

2. MacKean P, Gutkin C. Fewer medical students selecting family medicine. Can family practice survive? Can Fam Physician 2003;49:408-9 [Eng], 415-7 [Fr].

3. Wright B, Scott I, Woloschuk W, Brenneis F, Bradley J. Career choice of new medical students at three Canadian universities: family medicine versus spe- cialty medicine. CMAJ 2004;170:1920-4.

4. Senf JH, Campos-Outcult D, Kutob R. Factors related to the choice of fam- ily medicine: a reassessment and literature review. J Am Board Fam Pract 2003;16:502-12.

5. Statistics Canada. University tuition fees. The Daily Sept 1, 2005. Available from: http://www.statcan.ca/Daily/English/050901/d050901a.htm.

Accessed 2006 May 3.

6. Sullivan P. Medical student debt problems appear to be worsening. Ottawa, Ont: Canadian Medical Association; 2005. Available from: http://www.cma.

ca/index.cfm?ci_id=10026669&la_id=1. Accessed 2006 May 2.

7. College of Family Physicians of Canada, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada. National Physician Survey.

Mississauga, Ont: College of Family Physicians of Canada; 2004. Available from: http://www.cfpc.ca/nps/English/home.asp. Accessed 2006 May 2.

8. Duffin J. What goes around comes around: a history of medical tuition. CMAJ 2001;164:50-6.

9. Kwong JC, Dhalla AI, Streiner DL, Baddour RE, Waddell AE, Johnson IL.

Effects of rising tuition fees on medical school class composition and finan- cial outlook. CMAJ 2002;166:1023-8.

10. Beagan BL. Everyday classism in medical school: experiencing marginality and resistance. Med Educ 2005;39:777-84.

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