Record numbers of Canada's best and brightest medical graduates are having their careers stalled by a lack of residency spots, a problem that could snowball for doctors and their patients.

Medical school graduates have an MD after their name. But they still need to complete years of supervised training, or residency, in specialities such as family medicine, general surgery or neurology before they can be licensed to practise medicine in Canada.

"The system is too tight," said Dr. Genevieve Moineau, chief executive of the Association of Faculties of Medicine of Canada (AFMC).

The problem

On Wednesday, graduating medical students in Canada found out if they got a residency position in the second and final round for this year. It's called matching.

The number of unmatched Canadian medical graduates has climbed from 11 in 2009 to 46 in 2016 and to 68 last year. If nothing changes, it's projected that by 2021, the number of unmatched medical graduates could reach 140.

Why it matters

Patients have a right to care at the right time and place, including from physicians.

But the system to match residents needs to be more flexible, according to the AFMC. The group represents the country's 17 medical schools.

"Until I hear that every Canadian has a family doctor, I would consider that we do not have too many physicians," said Moineau.

She estimated it costs $250,000 to train a medical student in Canada.

"It is taxpayers' dollars that goes to support the training of these medical students, who are the best and the brightest … and to me [that] creates this moral imperative that we should have to actually enable them to complete their training so that they can care for patients."

On top of that, graduating medical students often go into debt to pay tuition and to support their training.

Both the public funds and tuition are wasted if graduates don't go into practice.

Kelly Lien, who hopes to become an emergency room doctor, receives the notice of her second-round match. She thinks the resident matching system is subjective. (Submitted by Kelly Lien)

The Canadian Resident Matching Service (CaRMS) uses an algorithm to match graduating medical students with programs.

Dr. Amit Persad applied to CaRMS in 2017 and wasn't successful. Serendipitously, Persad said, a neurosurgery position opened up in Saskatchewan and so he was hired outside of the formal matching process.

"Something that I realized when I was not matched is it's devastating. You feel like the world is over, and I felt really crummy," Persad recalled.

"If you let yourself feel that your personal worth is directly connected to what position you get in residency … you are giving yourself too little credit as a human being. You've gone through a lot of work to make it through medical school."

This week, Persad's letter to the editor on how to fix residency selection was published in the Canadian Medical Association Journal.

Persad said he wrote the letter to highlight how applicants are treated and the nuances that go into selection. He doesn't think there's anything wrong with the CaRMS algorithm itself or with the candidates themselves.

"I just don't think that we have good measures by which to determine whether a medical student is suitable for any given residency."

Dr. Amit Persad remembers how devastating it was to be unmatched. (Submitted by Amit Persad)

He said the selection seems to fall to a gut feeling on the fit of a candidate.

It's a sentiment shared by Kelly Lien, who dreams of becoming an emergency room doctor. She didn't match in the first round in March.

"I have an issue with how subjective the system is compared to the States," where candidates take a standardized test, Lien said.

Lien received good news on Wednesday, matching for family medicine.

Possible solutions

Persad suggests a rotating internship system to allow residents to work as a doctor in unspecialized roles to give them an opportunity to get a feel for many specialities, while the residency programs gain a better idea of how medical students function as doctors.

Earlier this year, the Association of Faculties of Medicine of Canada took an in-depth look at the problem and made several recommendations.

Until system-based changes like those suggested in the AFMC report are implemented, the 8% unmatched rate at U of T will rise annually. Twenty unmatched students is twenty too many. <a href="https://twitter.com/hashtag/carms?src=hash&ref_src=twsrc%5Etfw">#carms</a> <a href="https://t.co/boiI3jdWqY">https://t.co/boiI3jdWqY</a> —@mtaglione <a href="https://twitter.com/hashtag/CaRMS?src=hash&ref_src=twsrc%5Etfw">#CaRMS</a> round 2 results today .... where 1,500 residency-ready MDs will compete for 63 Canadian spots, most in Quebec (and half? of those will stay unfilled). <a href="https://twitter.com/hashtag/IMG?src=hash&ref_src=twsrc%5Etfw">#IMG</a> <a href="https://twitter.com/hashtag/DoctorShortage?src=hash&ref_src=twsrc%5Etfw">#DoctorShortage</a> <a href="https://twitter.com/drgigiosler?ref_src=twsrc%5Etfw">@drgigiosler</a> <a href="https://twitter.com/Doctors_NS?ref_src=twsrc%5Etfw">@Doctors_NS</a> <a href="https://twitter.com/SamCraggsCBC?ref_src=twsrc%5Etfw">@SamCraggsCBC</a> <a href="https://twitter.com/jddneary?ref_src=twsrc%5Etfw">@jddneary</a> —@EscoboomVanilla

A key one is for provincial governments to increase the number of residency positions, so that for every 100 graduates, there's 110 residency positions, to help meet the demand for physicians in Canada.

The AFMC called the falling number of residency spots a "high stress situation."

Some medical schools have recognized how depression symptoms and the workplace culture of residency programs contributed to the suicides of residents and medical school graduates who don't match.

Canadian medical schools offer supports such as career counselling to their students. Now the schools have extended those supports to those who are unmatched as well, Moineau said.

The AFMC also recommended not combining Canadian and international medical graduates in the second round of the match as most provinces now do.

Another option is to lower medical school enrolment though many communities across the country report physician shortages.