After he was passed over twice for a medical residency program, after he quizzed university officials and career counsellors about the reasons for his rejection, after exploring his legal options and shortly before ending his life, Robert Chu wrote a letter.

It was precise, but penned with passion. It showed the persistence the 25-year-old medical school graduate had demonstrated throughout his accomplished life.

But he also expressed his despair at what he believed is a flawed system used to match medical school graduates to residency programs — the final, obligatory stage in a doctor’s training.

Each year, a growing number of students do not get matched, putting the hundreds of thousands of dollars that provincial governments invest in educating and training future doctors at risk.

But going unmatched is also a professional and personal crisis for some of this country’s brightest young minds.

“Without a residency position, my degree … is effectively useless. My diligent studies of medical texts, careful practice of interview and examination skills with patients and my student debt in excess of $100,000 on this pursuit have all been for naught,” Chu wrote in the April 18, 2016, missive, which he addressed to Ontario Health Minister Eric Hoskins.

Read more: No easy cure for left-out medical-school grads

Copies of the letter were sent to several other politicians, including Prime Minister Justin Trudeau, Ontario Premier Kathleen Wynne, five Ontario universities and 10 news organizations, including a reporter for the Star.

Chu and a growing number of others denied access to residency have found themselves caught in a regulated system where provincial governments, based on an assessment of the needs of the population, dictate both the available student spaces in Canada’s 17 medical schools as well as the number of residency spots for medical school graduates.

Ontario, for example, cut 25 residency posts for the 2016/17 training year. But in a written response to questions, the provincial Health Ministry said the number of doctors in Ontario is projected to grow faster than the population, resulting in a average net increase of 650 physicians each year until 2025 even with reductions to number of residency spots.

In 2015, the first year he was rejected, Chu was among just 39 students out of almost 3,000 applicants who went unmatched. The next year, he was rejected again, and that number grew to 46.

This year, the number of unmatched students hit a record high of 68. Thirty-five of them were from Ontario, according to the Canadian Resident Matching Service, which runs the application process and the algorithm used to assign graduates to programs.

The head of the Association of Faculties of Medicine of Canada, Dr. Geneviève Moineau, said the unmatched students are “victims of a system that no longer meets their needs.”

“These smart, high-achieving individuals perceive that they are incompetent and not worthy compared to their peers. Several have gone on to develop significant health issues,” she wrote on the association’s website earlier this month.

She also referred to Chu’s case and the tragic outcome, which has rocked Canada’s medical education establishment.

“One of our young colleagues lost his life,” Moineau wrote, “largely because of what he had suffered from his ordeal with the match.”

Chu, who was born in Toronto and grew up in Burlington and, later, Amherst, N.Y., completed an undergraduate degree at the University of Toronto in three years instead of four. He was accepted to McMaster University medical school in 2012.

“That was what he wanted to do. He had invested so much time and effort into that. Even in high school he had set up a flow chart of goals that he wanted to meet. He had really high standards that he set for himself and goals that he wanted to achieve,” said his mother, Clara Chu.

When he began the intensive, yearlong residency application process in his final year at McMaster, he imagined himself becoming a radiologist. He tailored his training toward that discipline and even had several articles published in medical journals.

But he was among the 1.4 per cent of students in 2015 for whom the application and interview process — meant to match applicants’ preferred programs to the preferred candidates of universities — did not work out.

“There was nothing wrong academically; he connected with the patients. He just couldn’t understand what was wrong,” Clara Chu said. “The only thing they ever came up with is that he was too broad in his elective (courses), that he should have been more focused.”

Disappointed but determined, he began an MBA program and tried to keep up his clinical experience in hospitals. For his second try, he targeted residency programs in psychiatry and family medicine, believing them to be less competitive than radiology and with more available places.

“When he applied the second year … they said, ‘Well, wait a minute, you applied to radiology last year and wrote these (journal) articles and we’re kind of thinking that you’re not so committed to psychiatry,’” his mother said.

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Chu went unmatched again, but this time he began fighting against a ruthless system that, he wrote in his letter, provides no feedback, no advice and demands no accountability from decision makers.

He was also angered about the number of spots reserved in Canadian residency programs for international medical school graduates, who he said are often those who could not gain admission to Canadian schools and chose instead to study in the Caribbean, Ireland and Australia.

“I am frustrated by the injustice of this system — for myself, my peers and my potential patients. The enrolment of medical students has been steadily increasing over the last 10 years, by about 100 each year. The number of residency positions has not kept pace, and now it is decreasing,” he wrote.

“This makes no sense. What good is a doctor who cannot practise as one?”

Chu used provincial freedom of information laws to try to get details, feedback and insight about how his application had been handled and what might have gone wrong. He met with a lawyer to see if he had grounds for a case.

But never did Chu’s family worry about his mental health or see signs of depression or despair.

“That was Robert. He was very tenacious. He would always fight for what he believed in, on anything,” Clara Chu said, recalling how he had once challenged a high school principal who tried to prevent him from writing an article as editor of the school paper.

Chu wrote in his letter that he was sick of the applications and the interviews, sick of trying to sell himself to the guardians of the residency programs.

“I am finishing my MBA this year and, barring the presumably slight chance that I actually get into residency, I will pursue an alternative career in business,” he wrote.

But his second attempt to gain acceptance to the medical training program would ultimately be his last.

There was no withdrawal, no cry for help, Clara Chu said. The family took a trip. They returned home. It was September and the application process for a residency program was opening for a third time.

That is when Chu took his life on Sept. 5, 2016.

“I think it was that he was getting ready to write the letters to the universities again,” his mother said.

Correction - June 22, 2017: This article was edited from a previous version that mistakenly said Ontario cut 50 residency positions in 2014. In fact the reduction in the number of residency spots in Ontario since 2015/16 has been 25. As well, according to the province, number of doctors in Ontario is projected to grow faster than the population, resulting in a average net increase of 650 physicians each year until 2025 even with reductions to number of residency spots.

