Medical groups recommend sweeping reforms to resident training in Canada

A new report calls for sweeping reforms to postgraduate medical education in Canada, changes that could ultimately affect the delivery of healthcare in the country. Released in March, the report makes 10 recommendations, including a proposal to change the number and mix of general practitioners and specialists and a proposal to move to a competency-based curriculum. Postgraduate medical education refers to residency programs offered by Canada’s 17 faculties of medicine where those with an undergraduate MD degree train to become family doctors, surgeons and other medical specialists.

Mark Walton, assistant dean of postgraduate medical education at McMaster University, predicted it would take five to 10 years to fully implement the ambitious reforms. “This could have a rippling effect not only on postgraduate education and undergraduate education but also on healthcare delivery in the country,” he said.

The study, called “The Future of Medical Education in Canada: a Collective Vision for Postgraduate Medical Education,” (PDF) was conducted by the Association of Faculties of Medicine of Canada (AFMC) and the country’s three main certifying bodies: the Collège des médecins du Québec, the College of Family Physicians of Canada, and the Royal College of Physicians and Surgeons of Canada. It echoes many of the observations and recommendations from a study on undergraduate medical education released in 2010.

The postgraduate report calls on residency programs to produce the right number, mix and distribution of general practitioners and specialists. The healthcare system needs a balance of both, the report noted, but an insufficient number of residents choose the generalist route. In addition, many segments of the population such as aboriginal people, the homeless, those in rural and remote communities and, increasingly, the elderly face significant barriers in accessing medical care. “We need to respond to the baby boomers and the aging of our population,” said Nick Busing, president and chief executive of AFMC.

The proposal isn’t new but it remains stubbornly difficult to implement. What’s needed, Dr. Busing said, is for provincial governments and medical schools to establish a national plan that sets the number and type of doctors. “We need a better process to do some central planning,” he said.

Postgraduate medical education programs should provide residents with opportunities to learn and work in diverse environments and with underserved populations, the report recommends. Traditionally, residents complete most of their training in large, urban teaching hospitals. This has started to change in recent years with several medical schools such as the Northern Ontario School of Medicine – a joint initiative of Lakehead University and Laurentian University – adopting a distributed medical education model that places residents in community hospitals, clinics and family practices. But more needs to be done, Dr. Busing said: “We really need to educate our future physicians in the places where they will end up practicing and have experiences in those environments.”

One of the report’s most challenging recommendations calls for a shift to a competency-based curriculum, which would require residents to obtain a certain skill-level regardless of how long or how little time it takes. “It’s a different way of thinking about medical education,” Dr. Busing said. It will require medical schools to provide residents with ongoing assessments and evaluations rather than a single final exam.

The time-based system used now is logistically easier to manage, said McMaster’s Mark Walton. “If everyone is becoming competent at different times, then it becomes difficult to manage the system as a whole. We may end up heading towards a hybrid system of time and competency,” he suggested.

The report also calls for postgraduate programs to give residents supportive learning and work environments and to address such issues as resident fatigue, sleep deprivation and the so-called “hidden curriculum” – the informal culture prevalent in the profession that places greater value on some specialties and subspecialties than others.

The expansion of enrolments in medical school and residency training in recent years has fueled greater demand for clinical teachers – practising physicians who train residents, often on a volunteer basis. “The demands we are putting on these people is enormous,” Dr. Busing said. Quebec has introduced a payment system for clinical teachers, he noted, and the report recommends that the rest of the country follow suit.

Other recommendations call for an easier and smoother transition between undergraduate and postgraduate medical education and more flexibility for residents to switch specialties during training. The report recommends streamlining the complex governance system that oversees medical education as well as simplifying the costly, time-consuming accreditation processes for postgraduate programs.

The earlier report on undergraduate medical education made 15 recommendations for changes to MD programs. Much has changed since its release two years ago, said Dr. Busing. Some medical schools have adopted a more distributed education model while others have introduced more public and preventative health training into their curricula. “I would say we are doing very well,” said Dr. Busing.