Q: What do you call the student who finishes last in medical school class?

A: Doctor.

That old joke is a reminder that the most challenging aspect of a career in medicine can be getting into medical school. Medical students rarely flunk out and graduating pretty well guarantees a good-paying job for life.

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Or at least it did until recently.

Of late, there is much weeping and gnashing of teeth over the growing number of students graduating with a medical degree but unable to secure a residency spot. Without residency training, and the licensing that follows, a MD cannot practise.

This year, 2,980 young women and men will graduate from Canada’s 17 medical schools. They are vying for 3,308 residency spots. At first blush, it looks like there’s a job for everyone, and then some.

But matching a graduate to a residency spot is a complex process, overseen by the Canadian Resident Matching Service. Medical students apply to CaRMS in one or more specialties; committees select who they wish to interview and rank them; graduates rank the programs and, finally, an algorithm spits out a match, and the student is legally bound to take that residency spot.

The raw numbers are misleading because there are 917 spots in Quebec, many of which require fluency in French. Practically, that means there are fewer spots for English-speaking graduates than there are residency spots.

More importantly, medical school graduates do not necessarily want to work in specialties where there are jobs available. This leads to mismatches.

This year, there are 115 graduates of Canadian medical schools who are unmatched – meaning unemployed. There are also 78 jobs unfilled – 65 of which are in family medicine. (And this is after international medical graduates are brought into the equation, which is a whole other discussion.)

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Clearly, something is not working.

Not getting a residency spot after four years of medical school and the accumulation of debt that comes with it can be emotionally and financially devastating. Medical school tuition fees range from $7,000 to $27,000 annually in Canada, plus living expenses. Medical students graduate with more than $100,000 in debt on average; $250,000 in debt is not unusual and it often grows during residency.

Taxpayers are also paying a price. It costs about $250,000 to train a medical student, above and beyond tuition fees. Yet, Canadians are not getting the doctors they need, where they need them.

This raises some difficult questions, including:

Is every medical school graduate entitled to become a practising physician?

Do we have an adequate number of residency spots and, just as importantly, the right kind of residency spots?

Is there a better way of aligning the desires of medical students and the needs of society?

Medical school admission often comes with a sense of entitlement even though few, if any, graduates of other programs are guaranteed work at graduation – not lawyers, not nurses, not plumbers, not philosophers and not hairdressers.

What is different for physicians is that residency, which can last up to seven years, is an extension of their education. It’s a bit absurd to do four years of medical school if you will have no opportunity to put it into practice.

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Without a doubt, some medical school graduates should not become practising doctors. What’s troubling with the current situation is that there are candidates who are qualified but have been left out in the cold by a bizarre game of algorithmic musical chairs.

The most commonly touted solution to the mismatch problem is to simply add more residency spots . That’s a well-worn path in Canadian health care: Scream “shortage” and throw more bodies/money into a flawed structure.

But this is not simply a numbers game. We have more doctors, in absolute numbers and per capita, than ever before. But we have a growing problem of maldistribution. Everyone wants to be a specialist and everyone wants to practice in a big city – largely because our pay scales tell us that is what is valued.

We don’t need more doctors, we need more more general practitioners, especially in rural and remote areas. If medical students don’t want those jobs, then perhaps we’re not attracting the right people to medical school.

Becoming a doctor is hard. It’s also a privilege. We need a system that ensures the right doctors are working in the right places, not one where personal desires can trump societal needs.