Irections For Esidency Ducation: February

February
2009
DIRECTIONS FOR
RESIDENCY EDUCATION,
2009
A FINAL REPORT of the CORE

COMPETENCY PROJECT
A Collaborative
Project of the Royal
College of Physicians
and Surgeons of
Canada and the
College of Family THE ROYAL COLLEGE of THE COLLEGE of
PHYSICIANS and SURGEONS of FAMILY PHYSICIANS of
Physicians of Canada CANADA CANADA
DIRECTIONS FOR RESIDENCY EDUCATION, 2009
A Final Report of the Core Competency Project
The Royal College of Physicians and Surgeons of Canada

Office of Education
774 Echo Drive
Ottawa, Ontario K1S 5N8 Canada
Telephone: 1-800-668-3740 or 613-730-8177
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Web site: http://rcpsc.medical.org
E-mail: corecompetency@rcpsc.edu
Writing Team: Rani Mungroo, Jason R. Frank, Aubrie McGibbon, Jonathan Nagle
Copyright © 2009 The Royal College of Physicians and Surgeons of Canada.

All rights reserved.
Printed in Ottawa, Ontario, Canada
How to reference this document:
The Royal College of Physicians and Surgeons of Canada. Directions for Residency Education, 2009.
A Final Report of the Core Competency Project. February 2009. Ottawa: The Royal College of
Physicians and Surgeons of Canada.
© 2009 THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA

DIRECTIONS FOR RESIDENCY EDUCATION, 2009 ii
Table of Contents
PREAMBLE 1
INTRODUCTION 2
SECTION 1: BACKGROUND 3
Recurring issues in Canadian postgraduate medical education 3
History of the movement toward the Core Competency Project 5
Societal health needs 7
SECTION 2: PROJECT HISTORY TIMELINE 10
SECTION 3: PROJECT ACTIVITY TIMELINE 12
SECTION 4: PROJECT METHODOLOGY 14
SECTION 5: KEY FINDINGS 19
Premature career decision-making 19
Barriers to switching career paths 26
Quality postgraduate medical education 29
SECTION 6: DISCUSSION AND ANALYSIS 35
The timing of career choice and satisfaction with choice 35
Switching and re-entry 37
The effectiveness of the PGME system in responding to the needs of trainees and society 40
Competency-based Education 43
SECTION 7: DIRECTIONS FOR THE COLLEGES 44
APPENDICES 46
1: Glossary 46
2: National Physician Survey 2007 data analysis 48
3: Summary data from the CCP survey 59
4: CaRMS survey comparison 62
5: Electives policies of Canadian medical schools 63
6: CaRMS residency match, 2002–2008 66

DIRECTIONS FOR RESIDENCY EDUCATION, 2009 iii
7. Re-entry policies of Canadian medical schools 67
8. Number of re-entry trainees, 1991–2008 71
9. Switching between training fields, 2000–2007 72
10. Changes among training field groups, 2000–2007 73
REFERENCES 74
LIST OF TABLES and FIGURES
Figure 1: Historical recognition of medical specialties and subspecialites in Canada, 1919-2009 4
Table 1: Literature review methodology summary 15
Table 2: Commentaries and Focus Groups methodology summary 17
Table 3: Preparedness for residency training 21
Table 4: Medical students’ satisfaction with level of exposure to specialties 23
Figure 2: Canadian medical residents’ level of satisfaction with their chosen career discipline 34
Figure 3: Canadian medical students’ level of satisfaction with their chosen career discipline 34
Table 5: Reported barriers to switching disciplines in residency 38
Figure 4: Percentage of physicians who considered switching disciplines during residency training 39
Figure 5: Percentage of medical residents who have considered switching disciplines 39
Table 6: Views of the current postgraduate medical education system 41
Table 7: Level of satisfaction with residency training program 41
Figure 6: Is the Canadian medical education system effective at meeting the needs of those it serves? 42

DIRECTIONS FOR RESIDENCY EDUCATION, 2009 1
Preamble
The primary objective of specialist postgraduate medical education is to prepare an
appropriate number and mix of consultant physicians and surgeons, with the requisite
knowledge, skills and attitudes to meet the needs of Canadian society.1
Postgraduate medical education (PGME) is that essential element of the physician training pipeline that
prepares doctors for practice. Enhancing the quality of Canadian PGME is an iterative, evolutionary and
collaborative process enabled by sound, evidence-based, decision-making in the context of Canadian health
care and societal needs. Ensuring that medical education is responsive to societal needs is a challenging
issue. In 2005, the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians
of Canada were asked by the Canadian Medical Forum to address three complex, interrelated and recurring
issues in Canadian medical education: (1) the quality of PGME, including the balance between generalism
and specialization; (2) barriers to switching career paths; and (3) premature career decision-making. The
goal of this report is to provide informed, evidence-based information on these core issues that will support
further discussion and help to build wider collaboration and consensus.

Introduction
Postgraduate medical education (PGME) plays a vital role in the preparation of a health care workforce for
any country. PGME policy decisions that shape this essential health care endeavour must be informed by
the best available data and by a consideration of numerous interrelated issues and stakeholders. Canadian
residency education is that critical path for undifferentiated medical school graduates to receive higher and
focused training in preparation for practice in diverse settings. In addition, for those re-entering training
from a variety of medical backgrounds, Canadian PGME is increasingly a source of further training for a
specific career. Canada’s PGME system is respected worldwide, trusted by Canadians, and known for
producing graduates of exceptional competence.
The purpose of this report is to facilitate the creation of evidence-based policy on three issues that have
been debated in the medical education community for a number of years. The directions of the Core
Competency Project should inform decisions on the PGME system to meet the needs of patients and the
profession for the 21st century. Fundamentally, the Core Competency Project (CCP) is a re-examination of
three recurring issues in Canadian PGME:
1. Are the structures and processes of the PGME system, within the scope of the Royal College of
Physicians and Surgeons of Canada (RCPSC) and the College of Family Physicians of Canada
(CFPC), designed for the best possible output of physicians to meet societal needs (“Quality
PGME”)?
2. Does the PGME system allow for appropriate switching of residents or physicians between
career disciplines (“Flexibility”)?
3. Does the PGME admissions system allow medical students to make appropriate career choices
(“Career Decision-Making”)?
In April 2005, the Council of the RCPSC in partnership with the CFPC supported the development of the CCP
to identify, define and analyze factors that contribute to these issues and to propose recommendations for
addressing them. Stakeholders labeled these issues as:
 the quality of postgraduate medical education

 barriers to switching career paths
 premature career decision-making.2
This report integrates evidence gathered during the 2005–2008 research and consultation phase of the CCP
from several methods of enquiry:
 a literature review
 policy analysis (including electives and re-entry policies)
 the CCP survey
 a qualitative review of medical expert commentaries and focus groups
 database analysis (CAPER data, the 2007 National Physician survey and the CaRMS post-match
surveys)
 a systematic review on competency-based education.
Efforts to enhance Canadian PGME should be driven by societal needs in the context of an evolving
profession, a dynamic health care system, and the ever-changing practice of medicine. The RCPSC and the
CFPC, in their capacity as the leading Canadian organizations of medical specialists, have undertaken to
systematically bring together all available evidence and stakeholders to identify, analyze and assess the
information relevant to these concerns and to assess possible directions for long-term change.

Section 1: Background
Recurring issues in Canadian postgraduate medical education
Position papers, reports of working groups, resident and medical student organizations, commissions, task
forces and editorials have all highlighted recurring issues in the Canadian medical education system. Three
of these in particular, have been grouped under the headings of “premature career decision-making”
(PCDM), “inflexibility” and “quality PGME”. These concerns have been linked to changes introduced into the
medical education and training system in 1993, when the rotating internship was abolished and Canadian
PGME fundamentally changed.3,4,5,6,7,8 Postgraduate medical training requirements were increased from
the one-year rotating internship followed by specialty training, to two years in an accredited program in
family medicine or the completion of 4-5 years of specialty training leading to certification by the RCPSC.9
This necessarily means that medical students are matched into a Royal College specialty or Family Medicine
residency training in medical school. A perception found in some of the literature, commentaries and focus
groups, is that due to the competitive nature and early timing of the match, this career selection can occur
too early, limiting the amount of clinical exposure medical students are exposed to prior to making
decisions and thus compromising their ability to make informed decisions.10,11,12,13,14
This is occurring within the context of an explosion in science, technology and expertise. In response to
such growth, physicians, like other professionals, have become progressively more specialized in order to
maintain high levels of expertise within increasingly focused aspects of their discipline.15 It is widely
accepted that this specialization (and subspecialization) has significantly enhanced the quality of health care
outcomes by allowing physicians to develop and maintain expertise and competence within highly
sophisticated fields of medicine. A clear indication of the progressive specialization of medicine in Canada is
the proliferation of specialties and subspecialties that are recognized by the RCPSC. When the RCPSC was
first formed in 1929 it offered only two specialty qualifications: Fellowship in General Medicine and
Fellowship in General Surgery. Less than 80 years later, in 2009, the RCPSC recognizes 28 specialties, 31
subspecialties and 2 special programs (Figure 1). This dramatic growth of specialization in PGME and
physician practice is found not only in Canada, but in other jurisdictions as well.16,17,18,19
According to an influential 1996 RCPSC Report,
the primary objective of specialist postgraduate medical education is to prepare an

appropriate number and mix of consultant physicians and surgeons, with the requisite
knowledge, skills and attitudes to meet the needs of Canadian society.1
Given that these needs can vary so much from one part of the country to the next, and taking into account
the changes that have occurred in recent years in the PGME system, the Colleges have recognized the value
of an educational system that is sufficiently flexible to allow physicians to tailor their practices and training
to the particular requirements of the Canadian populations they serve. To ensure that this objective is
achieved, medical education in Canada has tended to support the view that training should follow a logical
progression from breadth to depth (i.e., from the undifferentiated medical student, to broad foundational
training, to focused advanced training, to generalist-specialist, or, in some cases, to subspecialist).
To help foster this progression, undergraduate medical education in Canada has a mandate to ensure that
medical students acquire a broad introduction to medical competence in preparation for PGME and are
exposed to a number of areas of medicine. In this model of education, students explore the range of
available options so that they can make informed decisions about their choice of career specialty. Once
physicians begin their residency training their educational experiences build upon a foundation of common
knowledge, skills and attitudes that is reinforced throughout residency and maintained throughout their

careers. As residents progress to more senior levels of training, they begin to focus on their desired scope of
practice and then make appropriate career choices (i.e., they decide to pursue generalist-specialist training
or subspecialist training).19 This approach has been criticized, however, on the grounds that the structure
and content of the PGME system do not always adequately promote or accommodate this logical
progression: medical students are required to match into Family Medicine or other specialty training
directly from medical school, thus obliging them to identify their preferred choice of specialty at an early
stage of an MD program. By this line of thinking, the structure of the system ultimately leads to a
premature emphasis on specialization in medical education, which may interfere with the educational
experience of undergraduate and postgraduate medical trainees.20 This context makes it imperative that
any changes to the PGME system are aligned with the changes currently taking place in medical education
and in society at large.

History of the movement toward the Core Competency Project
Developments within the Royal College

The concept for a Core Competency project has evolved from initiatives arising from the RCPSC, the CFPC
and the broader health care and medical education community. For example, the RCPSC’s Committee on
Specialties (COS) authored several reports in the mid-1990s that emphasized and expanded upon the need
for a generalist base in specialty medicine.
The authors of the 1996 Maudsley Report stated that a generalist base in specialty medicine implies “a
broad base of general knowledge, skills and attitudes common to all physicians and [provides] a substantial
foundation or base upon which specialty and subspecialty medicine is built” (p. 2).1 It should also be
pointed out that some of the key recommendations in the Report accentuated the need for the
development of a generalist base (p. 17–18).1
The development and maintenance of a common foundation and the practice of specialized
medicine are complementary rather than mutually exclusive … *T+here is a need to
emphasize principles of generalism during the residency, with a progression from
generalism to specialism during the residency period. A base of general knowledge, skills,
and attitudes is essential for all specialists, to be taught and reinforced throughout the
entire residency and also maintained throughout the entire career, by continuing
education, in order to facilitate the modification and change in specialist practice which will
inevitably evolve over the next decades [p. 2].1
Subsequently, in 1998, a report entitled A Re-examination of the Royal College Specialties and
Subspecialties (also known as the Langer Report)21 advocated the development of a core training model
and detailed the potential advantages and disadvantages of such a model. The Report suggested that in
such an approach “specialties will be grouped in generic categories where there are areas of strong
commonalities of principles and approach.”21 It noted that core training at the beginning of specialty
training in medicine, surgery, laboratory medicine, imaging, pediatrics, obstetrics and gynecology, and
population health specialties
will provide the general experience required to meet the educational needs common to
major disciplines. In addition, those general competencies expected of all specialists will be
included in the objectives throughout the residency.21
Among the benefits of such a model, the Langer report cited “consistency of development of training
programs across disciplines” and “improved flexibility for career choice among trainees.”21 Based on the
recommendations of these reports, the COS developed its Principles of Decision-Making, which included
that:
 All primary specialties must include a period of core training in order to develop a base of
generalist competencies. This will facilitate flexibility in training and emphasize the progression
from generalism to specialization.
 Generalist competencies are to be incorporated in the specialty-specific objectives of training
throughout residency.
 There will always be some areas of overlap in defining specialties and subspecialties. However,
disciplines that share significant overlap within the objectives of training should be aligned,
amalgamated or combined.22

In 2002 the Medical Stream Model (MSM) emerged at the Royal College in response to two issues: (1) an
application from General Internal Medicine to be recognized as a subspecialty of Internal Medicine; and (2)
an increasing push for more generalist-specialists. It was proposed that the MSM, while grounded in the
concept of a shared set of core competencies as the foundation for training within medical specialties,
would consist of three years of core training in the fundamentals of medicine followed by “specialization” in
disciplines currently recognized as subspecialties of Internal Medicine. Respondents mentioned that the
common curriculum would provide
longer, broader and more consistent general training than is now the case; increase
flexibility of career choice by delaying the decision point; facilitate the assessment of
training for residents who transfer to another specialty; enhance the development of
objectives for the core years and eliminate the ill-defined objectives of the overlap year.23
Although the concept of three years of common, core training was well received, the MSM was not
pursued beyond its consultation phase because of lack of support among stakeholders. Considering these
developments within the Royal College and in the broader medical education community, the Colleges
are ensuring that, through the present report, all available evidence is assessed in order to determine
any need for change.
Thus, the core competency approach is the logical culmination of much of the thinking on specialty
education that emanated from the RCPSC in the 1990s.
Developments within PGME

As the debates and issues surrounding core competency evolved within the Royal College, deliberations
simultaneously progressed in the broader medical education and health care community in Canada. On the
one hand, these deliberations focused on how best to modify training within medical specialties to enhance
generalist competencies and increase the integration of training across disciplines to provide better
coverage of the broad continuum of care. On the other hand, governments and regulatory authorities have
challenged the medical profession to find ways to make training broader yet more time efficient. Finally,
there are those who have argued that training should be more focused to respond to the exponential
growth in medical science and the expertise needed for practice.
The Canadian Medical Association’s 1986 report entitled Family practice training: continuing the evolution
(Cox Report) was the first to recognize the feasibility and merits of implementing a common and flexible
first postgraduate year (PGY-1) in Canada that would emphasize core training in subject areas common to a
number of disciplines. The report recommended that all faculties of medicine offer a flexible PGY-1
comprising three training streams. Of note is the recommended Stream 3: an objectives-based transitional
training stream that would provide “core training in subject areas common to a number of disciplines and
specific training in areas of major disciplines which could be eligible for some credit toward the training
requirements of the College of Family Physicians of Canada or of the Royal College of Physicians and
Surgeons of Canada.”24 The CMA’s first Invitational Conference on Flexibility in Career Choice (1997) built
upon the viewpoints of its earlier reports but was targeted specifically toward barriers to career change. It
recommended the implementation of a first-year program that would facilitate both generalist training and
streaming; the redesign of the undergraduate curriculum for the purpose of facilitating informed career
choice; and an examination of ways to partner with the government to meet the needs of society and a
flexible PGME system.25
A position paper prepared in 2005 by the OHRC (the Human Resources Committee of the Ontario Medical
Association)26 presented statistics on the impact of the Ontario physician shortage on family medicine,
provided recommendations on the recruitment of Ontario-trained physicians who currently work in other

provinces and countries, and recommended postgraduate reform and the development of a common PGY-
1 to allow for increased flexibility and re-entry. In making these recommendations, the OHRC felt that early
career decision-making and system rigidity had had a negative impact on student career choices and
strongly advised that increased flexibility, more time for decision-making and giving credit for training
already completed in other specialty programs must be improved.
The Canadian Medical Forum (CMF) Working Group on the Common PGY-1 was established in 2003 to
delineate a plan for a common PGY-1 year along with strategies for its implementation. The mandate of the
Working Group incorporated ideas for improving career flexibility, enhancing opportunities for generalist
training and reducing the demands on medical students for early career decision-making. The report
acknowledged that early career choice and flexibility have been long-standing issues in PGME, and that this
issue has also been shaped by undergraduate issues such as curricula, admissions policies, career
counselling, electives and the involvement of mentors. The CMF noted a lack of quantifiable evidence on
the topic of career flexibility. The recommendations from the Working Group were produced through the
participation and collaboration of the CFPC, RCPSC, CMA, Canadian Association of Internes and Residents
(CAIR), Canadian Federation of Medical Students (CFMS), Association of Canadian Medical Colleges (ACMC)
and other organizations. The Working Group considered many options and recommended the
implementation of a common PGY-1 driven by pedagogical principles, the need to prepare physicians to
meet societal needs, and the idea of providing generalist training.27 In addition, the Working Group also
concluded that the culture of premature career choice should be understood within the context of early
preferential selection, the large number of PGY-1 entry paths, undergraduate and postgraduate medical
education curricula, as well as individual career choice and societal need.27 These directions were not
pursued however.
Societal Health Needs

No doubt, the medical educational institutions serve dual purposes – as an educational institution it
services to the education and training of its students; and as part of the health care system it has the
responsibility for understanding and meeting the health care needs of the population. 28
Throughout the research phase of the Core Competency Project, Royal College’s stakeholders and others
who contributed their time and expertise in the focus groups, national survey, commentaries and in
Royal College Standing Committees, commented about the importance of understanding premature
career decision making, barriers to switching career paths and quality PGME within the context of
societal health care needs. This pursuit is fundamental to both Colleges and the profession. For
example, one of the Royal College’s goals, as specified in its Act of Incorporation, is to contribute to the
improvement of the health care of Canadians.29 This goal is also reflected in the College’s vision and
mission which specifies the organization’s objective of promoting excellence in health care and health
care policy. There have also been several separate yet inter-related developments at the College which
show a continuous alignment and responsiveness of Royal College practices to societal health needs:
 Adoption of the CanMEDS Physician Competency Framework in 1996.

 Development of criteria for Royal College recognition of specialties and subspecialties - one of
which requires the demonstration that societal health care needs are being met.
 The August 2007 partnership with the Indigenous Physicians Association of Canada (IPAC) on a
contribution agreement with Health Canada First Nations and Inuit Health Branch (FNIHB) to
develop, pilot and disseminate educational modules for PGME and CME for the purpose of
providing residents and physicians with the knowledge skills and attitudes to provide improved
and more culturally competent care for Canada’s Indigenous communities.

Meeting the health care needs of society is also enunciated in the College of Family Physicians of
Canada’s (CFPC) mission, goals and principles of Family Medicine. Two of the four principles of Family
Medicine state that
 Family Medicine is a community-based discipline. As a member of the community, the family

physician is able to respond to people’s changing needs, to adapt quickly to changing
circumstances, and to mobilize appropriate resources to address patients’ needs.
 The family physician is a resource to a defined practice population. The family physician views
his or her practice as a “population at risk”, and organizes the practice to ensure that patients’
health is maintained whether or not they are visiting the office.30
However, for the purposes of this initiative, the scope of the assessment of societal needs was limited to
the observed needs of leaders in medical education, members of the profession and health care experts.
Input of the general public was beyond the limits of the CCP. Given this limitation however, meeting the
health care needs of Canadians was an important concept represented in a number of questions in the
national survey and focus groups. The survey sought to identify, amongst other issues, whether
postgraduate medical education in Canada 1) is effective at meeting the needs of those it serves, and 2)
supports an appropriate balance of generalists and specialists to appropriately meet societies’ health
care needs. Similarly, the commentary and focus group questions sought the feedback and
recommendations from Fellows, residents and program directors that would meet the needs of the
profession and society.
“The Population Perspective”
The capacity to appreciate the determinants, ranges, and variations of health status and disease in the
entire community.31
Thomas S. Inui in The Medical School’s Mission and the Population Health noted that “the medical school
has a social responsibility to the population it serves” and that “physicians may be well-prepared for their
“narrow, biomedical responsibilities” but they must also be prepared to fulfill public expectations and
societal responsibilities.32 We would argue that by extension this view must apply to the entire
continuum of medical education including postgraduate medical education. The perceptions and
solutions to premature career choice and inflexibility in residency education must be viewed not only
within the requirements of the profession but also within the context of who is being served. Medical
education, its structure and influences, must therefore be driven by a framework of societal health
needs.
The Royal College’s Health and Public Policy (HPPC) Committee discussed the issue of defining and
assessing societal health care needs in 2006 and 2007 and acknowledged that creating such a framework
is essential as it is the “principal lens through which the Royal College assesses its programs and
activities, irrespective of whether meeting these needs is the direct responsibility of the Royal College.”33
Some elements of this framework are:
 A commitment to societal health care needs must be viewed as a prerequisite rather than
merely a priority;
 The framework of societal health care needs should adopt a population health perspective;
 Needs must be considered within the context of available resources;
 Societal health care needs must be clearly distinguishable from demand, utilization of services
and supply.34

In some of the research encountered, defining and integrating the population health perspective into the
medical education curricula is one way of ensuring that the “implicit, social contract that exists between
medicine and the public it serves” can serve to regain the public’s trust and confidence.35 An
understanding of this social contract, as White and Connelly noted, “would have great potential for
expanding the perspectives of the biomedical sciences” requiring medicine to “expand its horizons to
encompass not only cells, organs, and individual patients, but entire populations and the circumstances
in which they live, become ill, recover and die.” This impetus of re-defining the social contract between
medicine and society would provide the population perspective – the capacity to appreciate the
determinants, ranges, and variations of health status and disease in the entire community – and redefine
the role of the medical education system in finding solutions to premature career choice, barriers to
switching career paths and the finding an appropriate balance between generalism and specialization in
medical education.

Section 2: Project History Timeline

The concept for a Core Competency Project (CCP) evolved from initiatives arising from the Royal College
of Physicians and Surgeons of Canada (RCPSC) and the College of Family Physicians of Canada (CFPC) and
from the broader health care and medical education community. Milestones in the development of the
CCP can be summarized as follows:
1986 Canadian Medical Described the feasibility and merits of

Association: implementing a common and flexible PGY-1 year in
24
Cox Report Canada.
1996 Royal College: Examined the design of Canadian postgraduate

Maudsley Report medical education (PGME): “the development and
maintenance of a common foundation and the
practice of specialized medicine are
1
complementary rather than mutually exclusive.”
1998 Royal College: Advocated the development of a core training

Langer report model and detailed the potential advantages and
20
disadvantages of such a model.
1997 Canadian Medical Recommended the implementation of a first-year

Association: First program that would facilitate both generalist
Invitational Conference on training and streaming; redesign of the
Flexibility in Career Choice undergraduate curriculum for the purpose of
facilitating informed career choice; and an
examination of ways to partner with the
government to meet the needs of society and
25
ensure a flexible PGME system.
2002 Medical Stream Model Emerged at the Royal College in response to an

proposal application from General Internal Medicine to be
recognized as a subspecialty of Internal Medicine
as well as an increasing push for more generalist-
specialists. It was proposed that the Medical
Stream Model would consist of three years of core
training in the fundamentals of medicine followed
by “specialization” in disciplines currently
recognized as subspecialties of Internal Medicine.
No consensus was reached, and so the proposal
did not proceed.
2004 Canadian Medical Forum: Acknowledged that early career choice and
Working Group on the flexibility have been long-standing issues in PGME
Common PGY-1 and that these issues have also been affected by
undergraduate curricula, admissions policies,
career counselling, electives and the presence of
mentors. The Working Group considered many
options and recommended the implementation of
a common PGY-1 to prepare physicians to meet
27
societal needs.

2004 Royal College Council Was informed at its September 2004 meeting of
new work initiated by the Committee on
Specialties (COS) and the Health and Public Policy
Committee on a core competency model for
PGME.
2004 Royal College Executive Supported in principle at its December meeting the
Committee directions defined to date with regard to the
development of the Core Competency model
(Resolution 2004-057).
2005 Royal College Council In April, formally supported the further
development of a CCP for PGME that would aim (1)
to identify, define and analyze relevant factors to
optimize the structure of PGME and (2) to
recommend options for addressing them
(Resolution No. 2005-041).
2005–2006 Working Group in The COS recommended in October 2005 that the
Laboratory Medicine Office of Education coordinate a Working Group in
Laboratory Medicine for the purpose of discussing
and proposing the development of a core
competency model for the Laboratory Medicine
disciplines.
2005 AFMC (Association of At the conjoint meeting of the RCPSC Education
Faculties of Medicine) Committee and the AFMC Standing Committee on
Standing Committee on Postgraduate Medical Education in November
Postgraduate Medical 2005, the AFMC Standing Committee members
Education expressed their “collective support for limiting the
entry disciplines of the RCPSC programs and
moving towards the Core Competency Model of
Postgraduate Medical Education.”
2006 Core Surgery Summit A national meeting of leaders in surgical education

reaffirmed support for foundational competencies
that cut across the early years of surgical training
in Canada. At the same time, the group rejected
the idea of a “trunk and branch” system of surgical
training based on PGY-1 entry to “Surgery.”
2006 Canadian Federation of Approved a policy statement outlining support for

Medical Students the CCP and affirming nine principles in keeping
with the values of the CCP. This policy statement
supports the creation and implementation of a
postgraduate training system that encourages
greater flexibility, includes common training and
skills development, and does not require a second
match or increased length of postgraduate
training.

Section 3: Project Activity Timeline

The Core Competency Project (CCP) has progressed since 2006 as a result of the following activities.
2006 Creation of a National CCP Provided advice on the preparation,

Survey Advisory Group implementation and analysis of a national survey of
medical educators, practising physicians, residents
and medical students. Members included Royal
College Fellows, residents, representatives of the
Canadian Resident Matching Service (CaRMS), the
Canadian Association of Interns and Residents
(CAIR), la Fédération des médecins résidents du
Québec (FMRQ), the College of Family Physicians of
Canada (CFPC) and postgraduate and
undergraduate deans.
2006–2008 Literature review Synthesized and analyzed data from journal

articles, reports and grey literature on the three
key CCP themes. The review comprised OVID
MEDLINE and “reviewer- nominated” searches on
premature career choice, flexibility, career
satisfaction, generalism and residency structure. All
search strategies were developed in consultation
with an Information Specialist and all study designs
and publication types were included.
2007 Royal College call for Sought commentaries on the CCP from Canadian
commentaries medical education experts, representatives from
the Royal College specialty committees and the
National Specialty Societies. Study participants
were sent a letter of invitation requesting
submission of a commentary paper. The letters of
invitation outlined key questions on quality PGME,
career decision-making and flexibility.
2007 Focus groups Harris Decima Inc. conducted focus groups

involving resident members and physician Fellows
(Royal College and CFPC) in St. John’s, Montréal,
Toronto, London and Calgary in March 2007. An
online focus group was also conducted in April with
participants from Vancouver. In August 2007, face-
to-face focus groups were held with program
directors from Quebec City and Kingston, and
online focus groups were held with program
directors in Emergency Medicine, Family Medicine,
Core Medicine and Surgery. Seventeen focus
groups were held with a total of 74 participants.
2008 National survey Medical students, resident members (RCPSC and
CFPC), physician Fellows (Royal College and CFPC),
program directors and medical leaders were
recruited to participate in an online survey
between March 5 and June 30, 2008. The primary
objective was to gauge the opinion of these
stakeholders on the current PGME system and how

the system can best be improved. The medical

student survey closed on December 19, 2008.
2008 Qualitative review Systematic analysis of the transcripts of the CCP
commentaries and focus groups was conducted
under the direction of Lara Varpio, PhD.
2008 National Physician Survey Secondary analysis of results of the 2007 NPS,
data review using items relevant to the questions of the CCP.
2008 Systematic review Throughout the course of the CCP consultations
and literature review, competency-based
education emerged as a key element for improving
PGME. It quickly became apparent that within the
medical education community there was no unified
understanding of this concept. The difference in
the degree to which competency-based education
is implemented is well documented in various
jurisdictions. The Royal College is conducting a
systematic review of competency-based education
to determine a definition of competency-based
education that is universally acceptable or, at least,
can serve to improve our understanding of the
concept.

Section 4: Project Methodology

The research and consultation phase of the Core Competency Project (CCP), which began in 2005, used a
combination of methods to retrieve and synthesize data. These have included national focus-group
consultations with physicians, residents and medical students; commentaries from targeted individuals,
including medical education experts, specialty committee chairs, national specialty society presidents and
representatives of medical regulatory authorities; a thematic literature review; and a review of existing
data. Each method has applied specific research questions and definitions to frame the overall approach. It
should be mentioned that one of the limitations of this phase of the project was the budgetary implications
of the broad consultative approach that was keenly sought. Invitees to the focus groups, commentaries and
national survey were therefore limited to the following:
 Focus groups:
o Fellows and Resident members of the Royal College and the College of Family Physicians
of Canada (CFPC) (St-John’s, Montréal, Toronto, London, Calgary and Vancouver)
o program directors from Quebec City and Kingston and online focus groups with program
directors in Emergency Medicine, Family Medicine, Core Medicine and Surgery
 National survey:
o medical students, resident members (RCPSC and CFPC), Fellows (RCPSC and CFPC),
program directors and medical leaders
 Commentaries:
o Royal College specialty committees, national specialty societies and Canadian medical
education experts.
Literature review
The literature review research consisted of OVID MEDLINE searches on the topics of premature career
choice, flexibility, career satisfaction, generalism and residency structure. All medical subject headings
(MeSH) were developed in consultation with an Information Specialist at the University of Toronto’s
Department of Continuing Education and Professional Development. Search strategies and keywords were
then created for each theme, and searches were run on MEDLINE (1969–February 2008). All study designs
were included: randomized, controlled, prospective cohort, retrospective cohort, cross-sectional, survey,
controlled before-and-after studies, interrupted time series, paired design studies, pragmatic trials,
narrative reviews, systematic reviews, meta-analyses, and descriptive studies. Further, the following
publication types were included: peer-reviewed and non-peer-reviewed journal articles, technical reports,
government / public sector white papers (e.g., policy documents, thought pieces), letters to the editor,
commentaries and editorials (excluding those that did not provide suggestions for change or improvement),
and abstracts (for which no corresponding published paper could be identified). Table 1 provides a
summary of the protocol objectives and research questions for the literature review.
Qualitative review: Commentaries and focus groups

The RCPSC has been working in collaboration with Dr. Lara Varpio, Assistant Professor, Faculty of Medicine
of the University of Ottawa, on the analysis of the qualitative data gathered throughout the course of the
CCP. Dr. Varpio was tasked with advising the Royal College on the best approach to use in conducting an
analysis of previously collected qualitative data on the CCP. Dr. Varpio’s expertise in qualitative analysis
provided the study with a methodical process through which vast amounts of data were analyzed in depth
and with critical attention to project details. Given the broad range of input received from the commentary
authors and focus groups, this process proved to be judicious.

Data were gathered in the form of commentary papers and focus groups. Commentaries were requested
through letters of invitation to Canadian medical leaders, national specialty societies across Canada, and
Royal College specialty committee chairs. Commentary participants were chosen on the basis of their
defined area of expertise in the medical education field and according to their role within a Royal College
specialty committee or national specialty society. One hundred and fifty-seven letters of invitation were
sent to participants; a total of 56 commentaries were received. Focus groups led by a moderator from
Harris Decima Inc. were conducted in March 2007 with residents and physicians in St. John’s, Montréal,
Toronto, London and Calgary; an online focus group was conducted for Vancouver participants. In August
2007, focus groups were held with program directors in Quebec City and Kingston. Four online focus groups
were subsequently conducted with program directors in Emergency Medicine, Family Medicine, Core
Medicine and Surgery. In total, 17 focus groups were held with a total of 74 participants. The research
questions addressed in the commentaries and focus groups are summarized in Table 2.
TABLE 1 LITERATURE REVIEW
Objectives Research questions

1. Identify factors that influence 1. What factors influence a medical student’s choice of career?
career choices among medical a. Do some of these factors relate specifically to the choice of
students primary versus non-primary care?
2. Summarize medical students’ b. What are the recommended strategies for optimizing the
perceptions and attitudes career choices of medical students?
regarding the career decision- c. Does the timing of medical student career choice influence:
making process  Choice of specialty?
3. Identify issues related to  Postgraduate career satisfaction?
optimizing career choice to  Medical students’ perceptions and attitudes toward
determine best-practice career decision-making?
recommendations for 37
 Career mobility?
undergraduate medical or
2. What is the evidence for career mobility of residents and
residency structures and their
impact on postgraduate career physicians?
satisfaction a. What are the determinants for switching specialty by
4. Determine what the evidence is for residents and physicians? (e.g., sex, age, etc.)
career mobility among residents b. What are the barriers or enabling factors to career mobility
and physicians and identify barriers by residents and physicians?
or enabling factors for career c. Are these factors different for specialists and generalists?
mobility d. What is the rate of career mobility among residents and
5. Determine the importance of physicians?
generalism in postgraduate 3. What are the advantages and disadvantages of postgraduate
training generalist training?
6. Identify evidence for rates and 4. What are the models (in practice) for medical education
determinants of super- systems?
specialization in the physician a. What is the evidence base for medical education system
workforce and identify evidence of models?
36 38
the impact on societal needs b. Is there evidence to support their effectiveness?
7. Identify models, or suggestions for c. What are suggestions or theories for restructuring?
models, for residency structures 5. What is the evidence for postgraduate career satisfaction
39
and summarize evidence of their regarding choice of specialty?
effectiveness a. What are the factors that influence career satisfaction or
dissatisfaction within the context of premature career
decision-making

The Core Competency Project survey

The purpose of the CCP survey was to capture the opinions of medical students, residents, physicians,
program directors and medical leaders on the quality and efficiency of the medical education system in
Canada and to identify commonalities of opinion with respect to the need for long-term change. A Survey
Advisory Group was created in August 2006 to advise on the preparation of the national survey and to
ensure an appropriate level of support. Survey Advisory Group members included Fellows, residents,
physicians, representatives of CaRMS, CAIR and FMRQ, as well as postgraduate and undergraduate deans.
In addition, the Office of Education consulted and communicated with postgraduate and undergraduate
deans on a continuous basis to ensure the appropriate and timely distribution of the survey. After an initial
survey framework was developed by the Survey Advisory Group, Harris Decima Inc. was contracted to
finalize the development and distribution of the survey to all targeted groups and to present a report on
findings. The online survey was conducted with medical students, RCPSC and CFPC resident members,
RCPSC and CFPC Fellows, program directors and medical leaders between March 5 and December 19, 2008.
2007 National Physician Survey analysis

Responses to the 2007 National Physician Survey (NPS) were used as a data source. All data relevant to the
issues discussed in the Interim Report – career decision-making and quality PGME, including satisfaction
with career choice and preparation for future practice – were extracted for further assessment. Analyses of
the NPS results are presented in Appendix 2.
Systematic review of competency-based education

The objective of the systematic review is to establish a definition of competency-based education (CBE) for
the Royal College by exploring how CBE is defined within comparable jurisdictions and within the context of
medical education. Since the Interim Report was published, stakeholders have commented on the need to
address a “top-of-mind” within the project. Taking this into account, our preliminary research on
competency-based education revealed that there was no agreed-upon and widely used definition of CBE
across the spectrum of specialty medical education or across international jurisdictions. Because a
definition must form the foundation of the creation and implementation of any CBE program, we have
embarked on a systematic review process to derive a definition of competency-based education.
Search strategies were performed on MEDLINE, EMBASE, ERIC and web-based sources for non-peer-
reviewed publications. A MEDLINE search on February 7, 2008, retrieved 7827 articles. EMBASE and ERIC
were run on March 28, 2008, and retrieved 5343 and 728 articles, respectively. French-language articles
were retrieved separately for EMBASE and ERIC on August 12, 2008, obtaining 68 and 1, respectively.
English- and French-language sources were used, and all study designs were included in the review. There
are 29 international jurisdictions that the Royal College has assessed and deemed to be in alignment with
RCPSC criteria for the purposes of the training assessment of international medical graduates seeking
RCPSC certification. For the purpose of this review, these organizations were considered “comparable” to
Canadian institutions, and all studies originating from these jurisdictions were included. Combinations of
the following search terms were used: medical education, competency, clinical performance, outcome
measures, and curriculum. Additional articles were identified through reference lists or discussions with
experts. The team is the process of finalizing the data extraction for all articles that were included after two
levels of screening. A manuscript is being prepared for publication in early 2009.

TABLE 2 COMMENTARIES and FOCUS GROUPS

Issue Definition Research questions
1. Quality PGME The best possible use of residency 1. Do the large number of PGME
education to ensure the output of entry points have an impact on
highly trained and highly medical students’ selection of
functional practitioners who are the type and number of
best able to meet the needs of electives they pursue in the
Canadians. undergraduate years?
2. Is the current PGME structure
optimally designed?
3. Is there an adequate balance
between generalism and
specialization in training and in
practice to properly meet
societal needs?
4. How does the current PGME
structure affect the quality of
health care?
2. Premature career decision- A medical student’s commitment 1. Is this a problem? Do you
making (PCDM) to a specific career path without believe that medical students
adequate exposure to the breadth are actually pressured to
of available options. choose their specialty early in
their undergraduate training
before having the opportunity
to experience adequately a
broad range of electives?
What evidence of this is there?
2. Do you believe that the
matching process and the
number of PGME entry points
provide medical students with
the appropriate means for an
informed career choice?
3. What is the impact of the
timing of career choice on the
educational experience of
residents and the career
satisfaction of practising
physicians?
4. Does PCDM affect the quality
of health care?

3. Barriers to switching career The constraints faced by residents 1. Is this a problem? Is it difficult
paths (Inflexibility) and practising physicians in for residents and practising
changing career paths without physicians to switch career
having to re-start their training paths?
from the beginning or to 2. How does the system’s
substantially lose their flexibility affect future
accumulated educational credits. physicians’ career satisfaction?
3. Are there additional means for
improving the system’s
flexibility, such as improving
credentialing or using
additional routes to re-entry?
4. Does this issue affect the
quality of health care?

Section 5: Key Findings

In 2007, the CCP Interim Report presented evidence from a literature review, a preliminary analysis of
commentaries and focus group consultations, an analysis of institutional survey reports (from the CaRMS
post-match surveys, the CAIR resident switching survey, the 2007 National Physician Survey (NPS), and the
CAPER Annual Census of Post-M.D. Trainees) and consultations with medical schools on their electives
policies and re-entry requirements. At the beginning of the research and consultation phase of this project,
the Colleges encountered several challenges, including a lack of concrete evidence to indicate the true
extent and impact of premature career decision-making and system inflexibility on the quality of the PGME
system in Canada. Hence the main goal of this research and consultation phase was to gather evidence on
these issues that would allow for more informed decision-making. During this past year, the Colleges have
finalized several research projects that supplement the findings presented in the Interim Report. These
comprise a qualitative review of the focus group and commentary data, the CCP survey and a secondary
analysis 2007 NPS survey. A comprehensive summary of findings from all research endeavours is presented
below, organized by CCP theme.
Premature career decision-making

Premature career decision-making has been defined as a medical student’s commitment to a specific career
path without adequate exposure to the breadth of available options. The key questions that guided this
research were as follows:
 Is premature career decision-making a problem? Do you believe that medical students are
pressured to choose their specialty early in their undergraduate training before having had the
opportunity to experience adequately a broad range of electives? What evidence is there that
this is or is not the case?
 Do you believe that the matching process and the number of PGME entry points provide medical
students with the appropriate means for an informed career choice?
 What is the impact of the timing of career choice on the educational experience of residents and
the career satisfaction of practising physicians?
 Does premature career decision-making affect the quality of health care?
The discussion that follows presents highlights and patterns in CCP research findings under the headings
Origins of the issue and the timing of career choice and Career choice influences.
Origins of the issue and the timing of career choice

In 1993 postgraduate medical training requirements changed as the one-year rotating internship was
abolished.40 According to a report of the Association of Faculties of Medicine of Canada (AFMC; formerly
the Association of Canadian Medical Colleges), it was at this point that “the amount of clinical exposure
medical students accumulated prior to making decisions in choosing their specialties started to become
more and more limited.”41
The general context within which these concerns originate has also been linked by others to the 1993
changes in the post-medical education training requirements and the end of the rotating internship.3,4,5,6,7,8
The current residency selection process and clerkship drive career decision-making to
earlier years and distort the content and viability of the fourth year of medical school by
forcing students to choose electives to enhance their match prospects rather than allowing
them to experience the breadth of possibilities that medicine offers.27

Students are pressed to decide early, usually after only slightly more than a year of brief
exposure to specialties in clinical clerkships. Gaining insight into one’s aptitudes and
professional priorities, especially at a young age, is a difficult task. Guessing how those
strengths and needs might evolve over a lifelong career is even more challenging.42
Commentary authors were also generally unanimous in their view that medical students choose a
specialty at too early a stage in their training, with very little opportunity for broad exposure to all
aspects of medicine. Commentary authors noted:
I have seen many student residents who made their decision [too early], focused their
medical experience to that end [to the loss of much of the rest of the medical school
experience] and do not belong or want to be in that training scheme (C1012).43
At present, medical students have to choose a specialty too early in their stage of training
with very little opportunity to re-enter training after a period in practice … *and+ only after
short exposure to the various specialties and limited clinical experience (C1053).
How can one expect a third year medical student to make a career choice when the student
is still learning basic and applied clinical sciences in the formative years of becoming an
undifferentiated doctor? (C1024)
In correspondence to the Director of Education at the Royal College in 2003, Drs. Sarita Verma and Richard
Birtwhistle, as co-chairs of the Association of Canadian Medical Colleges (ACMC) Standing Committees on
Postgraduate and Undergraduate Education, noted that the increasing anxiety faced by medical students in
making an early decision about what specialty they may want to practise, as well as the extreme
competitiveness of the system, are compounded by the large number of PGY-1 entry points and limited
specialty residency positions. This compels students to choose all their electives in one preferred specialty
in order to increase their chances of matching.44 The committee co-chairs further suggested that since
several programs share common training for the basic clinical year, some specialties could be removed
completely from the PGY-1 entry level.44 This view was reiterated by the committee’s co-chairs for 2006,
who acknowledged that the complexities of early career decision-making had been under discussion for at
least two years and that the committee was in general support of a reduced number of entry streams, “the
principle of reduc[ing] angst over early decision-making for students” as well as “the acquisition of
consolidated skills in a broad range of medical areas.”45
Judging from the commentary submissions, however, although there was significant agreement that the
issue of premature career choice is important, there was no consensus as to its causes. One author noted
that career choice anxiety
is more a result of the competition for specific specialties and the relatively limited number
of opportunities to enter some of the more competitive areas – the paradox lies between
student choice of career and societal needs as determined and defined by provincial
government control over various specialty positions (C1049).
As the same author noted:
No matter what type of selection takes place in the final year, whether into 10 disciplines or
thirty, the selection process will involve choosing electives, letters of references and
interviews – delaying entry will not delay the decision-making process (C1049).

Others offered the following views
The reduction of Royal College entry points may help; however, it is unlikely to change very
much unless the current method of undergraduate training and the clerkship experiences
are reviewed (C1009).
Having students enter into a core year as an undifferentiated student does not necessarily
address this issue (C1022).
By contrast, the CCP survey results indicated a high degree of satisfaction with career choice. The
majority of respondents within each respondent group believed that most medical students are satisfied
with their chosen career discipline (medical students, 95%; all residents, 90%; all physicians, 92%;
program directors, 77%; medical leaders, 80%).46 Similarly, more than three quarters of program
directors feel that contemporary medical students are satisfied while four in five medical leaders believe
that contemporary medical students are very or somewhat satisfied.47 Responses to the 2007 NPS were
used as a data source, and all data relevant to satisfaction with career choice were extracted for further
assessment. In the NPS, almost three quarters (73%) of third and fourth year medical students reported
being satisfied or very satisfied by the exposure that they had received to different medical specialties48,
while 61% of all third and fourth year students either agreed or strongly agreed that they felt prepared
for residency training (see Table 3).
TABLE 3: PREPAREDNESS FOR RESIDENCY TRAINING

% of responses
Medical training has prepared
you (or will prepare you) for 1st year or année 2nd year 3rd or 4th year All students
residency training préparatoire (n = 897) (n = 781) (n = 1109) (n = 2819)
Strongly agree 10.4 6.7 14.0 10.7
Agree 37.6 42.6 46.9 42.9
Neutral 38.7 30.9 21.1 29.3
Disagree 7.2 14.1 12.4 11.2
Strongly disagree 2.2 2.0 2.6 2.3
No response 3.9 3.7 3.1 3.5
Total 100 100 100 100
Data source: National Physician Survey 2007
With respect to choosing a career discipline, half of all physicians found it difficult to choose their discipline,
while program directors and medical leaders viewed choosing a discipline as somewhat or very difficult for
medical students. However, almost half of medical students and residents surveyed had little difficulty in
choosing a career discipline. A summary of the findings of the CCP survey is provided in Appendix 3. Two
questions from the 2000–2006 Canadian Residency Match Service (CaRMS) survey were also analyzed as
they relate to satisfaction with choice: (1) Do you plan to complete training in the discipline to which you
were matched? (2) If the opportunity were available, would you plan to change your residency discipline?
The data show that a small proportion of medical students indicate dissatisfaction with their career choice
(Appendix 4).

Career choice influences

The factors associated with career choice in medical education are varied yet interrelated and may
significantly influence possible solutions to premature career choice. The following factors were revealed in
the thematic literature reviews and commentaries.
Medical school environment. The undergraduate curriculum performs a critical role in providing students
with the clinical and academic exposure they need to make informed decisions about their choice of career
path. A wide range of medical education literature underscores the importance of the undergraduate years
in influencing student career choice.49,50,51,52,53,54,55,56,57,58 Dobson notes, for instance, that “*m+edical
training is diverse and complex and the ultimate goals of it are difficult to define; however, a primary
objective of undergraduate training must surely be to ensure that all students acquire the basic knowledge,
attitudes and clinical skills necessary to enable them to deal with the problems that are likely to be present
in their future practice.”59 In his study of medical school clinical experiences on student career preferences,
Brooks60 notes that specialty choice changes dramatically during medical school, moving away from
primary care practice toward the surgical specialties. The factors cited as most influential in career choice
were clerkship experiences, contact with a faculty member, the challenge and diversity of the work, and
enjoyment of patient contact. More specifically, research has shown that the general level of exposure
early in medical school through electives or clerkship experiences can facilitate or exacerbate career
choice.3,60,61,62,63,64,65,66
In the 2007 NPS, when asked about topics that have been covered in their medical studies, the majority of
medical students responded that they had been exposed to Family Medicine rotations, evidence-based
medicine, end-of-life issues, Internal Medicine, communications skills, and collaborative or interdisciplinary
care. However, hands-on teaching, hands-on research, emergency surgery, intensive care unit practice care,
minor surgery, Aboriginal health and coronary care unit practice had not been covered by a majority of
students (Appendix 2, Table 8).
A similar diversity in trends was observed when medical students were asked about their level of familiarity
with a variety of disciplines. Medical students reported being very familiar with the work of Family
Physicians (73%), Obstetrics and Gynecology specialists (58%), Internal Medicine specialists (57%), and
Surgery specialists (54%), whereas less than half reported being very familiar with the work of Psychiatry
specialists (48%) and Pediatrics specialists (48%) (Appendix 2, Table 9).
Medical students were asked to rate on a five-point scale their satisfaction with their level of exposure to
different medical specialties (Table 4). Seventy-three percent of third and fourth-year students reported
being satisfied or very satisfied with their exposure to different medical specialties. Approximately 6%
reported being dissatisfied or very dissatisfied with the exposure they had received to different medical
specialties.
There are differing views in the literature, however, as to whether exposure to a discipline is positively
correlated with students’ choice of that discipline67,68,69,70,71,72,73 or with a halt in the declining recruitment
to some specialties or changed attitudes toward a specialty.57,70,74,75,76,77 Herold and colleagues57 found that
“longitudinal primary care training did not influence students to choose residencies in primary care.”
Similarly, Harvey and colleagues note that “although exposure to a discipline is necessary for informed
decision-making, it alone does not seem to be sufficient to generate increased popularity.”61 Evidence for
this conclusion was derived from the fact that between 1994 and 2004, while most undergraduate medical
programs introduced mandatory rotations in both Anesthesia and Family Medicine, the proportion of
applicants who actually selected this specialty as their first choice decreased from 32.4% to 26.4%, and the
number of unmatched family medicine positions after the first round of the match increased from 20 in
1994 to 124 in 2004.77

Electives. The evidence seems to be more consistent with respect to the impact of electives on career
choice. Kassam and colleagues3 conducted a comparison of students’ elective choices before and after the
abolition of the rotating internship in 1993 by examining student elective choices in the 1992 and 1994
undergraduate classes at the University of Alberta. They concluded:
In total, 13% of the class of 1992 and 52% of the class of 1994 answered that residency had a primary
influence on their elective choices. Residency concerns did have a significant influence on elective
choices and the choice of electives was narrower after the abolishment of rotating internships at the
University of Alberta [p. 471].3
TABLE 4 MEDICAL STUDENTS’ SATISFACTION WITH LEVEL OF EXPOSURE TO SPECIALTIES
% of responses
1st year or année 2nd year 3rd or 4th year All students,
Level of satisfaction préparatoire (n = 897) (n = 781) (n = 1109) (n = 2819)
Very dissatisfied 2.3 1.7 0.7 1.5
Dissatisfied 12.9 12.9 5.5 9.9
Neutral 38.9 29.4 17.1 27.4
Satisfied 36.8 47.4 60.1 49.4
Very satisfied 4.9 4.9 13.3 8.1
No response 4.1 3.7 3.2 3.7
Total 100 100 100 100
Data source: National Physician Survey 2007
Among the respondents to the CaRMS 2006 post-match survey, 59% indicated that they had completed
more than 50% of their electives in their first-choice discipline.78 Changes are currently underway to rectify
this issue. At the most recent meeting of the AFMC, the undergraduate and postgraduate deans passed the
following combined resolution:
Electives in the Clinical Clerkship must be organized so that each student has had an
elective experience in a minimum of three different disciplines, each of which shall take
place for a minimum of two weeks … This resolution was passed in order to promote
diversification and generalism in medical education, while discouraging excessive
concentration in a single discipline.79
A scan of electives policies (Appendix 5) shows that this policy has been or is being implemented
throughout medical schools in Canada. Currently, 13 out of a total of 17 schools require their medical
students to have an elective experience in a minimum of three different disciplines, each of which must
take place for a minimum of two weeks.80 More variety in electives exposure is deemed advisable, and in
some cases program approval is based on whether the program can be shown to be broadly based.81 As the
University of Saskatchewan’s policy states:
The MD program is designed to ensure that participants graduate with a common

foundation of knowledge, skills, values and attitudes. This general professional education
prepares undifferentiated graduates for subsequent education in primary or specialty care
areas.82
Authors of commentaries submitted to the CCP alluded to the fact that undergraduate medical education
experience is an essential element of ultimately becoming a well-rounded doctor. “It must be recognized
that one has to become a good doctor in all aspects of knowledge, skills and attitude before one can go

further to become a good specialist.” (C1024). “Premature career decision making likely affects one’s
educational experience more as a medical student than as a resident” (C1033). Even so, some authors
noted that those who choose to pursue a broader elective experience may in fact be compromising their
chances of being matched. These candidates are often erroneously viewed as “undecided” or “less
committed” (C1034) (C1004).
Role models. The influence of mentors and role models in the decision-making process has been
demonstrated in numerous studies,71,83,84,85,86 which generally show that the presence of role models is an
integral part of the medical education experience and a powerful force in “shaping the values, attitudes,
behavior and ethics of medical trainees.”87 Role models have a strong influence on the career choice of
medical students. The literature shows that a high degree of exposure to role models in Surgery, Internal
Medicine, Physical Medicine and Rehabilitation, Pulmonary and Critical Care Medicine, and Primary Care
are associated with trainees’ choice of those specialties.87,88,89,90,91,92,93 A 1997 study of graduating students
at McGill University investigated whether there was a link between exposure to clinical role models during
medical school and students’ career choices. The authors concluded that exposure to role models who
practise in a particular field is strongly associated with the decision to choose that career.94 Other studies
show that the presence of a faculty advisor and career counselling service can also have a large impact on
resident satisfaction with choice of discipline.95,96,97 The timing of an interaction with a role model is also
key. In one study, 65% of the students who were surveyed encountered their role models before making
their choices and at a point in the decision-making process when interactions with a mentor can have more
influence.84 The study further concludes that choosing a physician role model later in medical school leaves
less time for such an interaction to influence or inform students' specialty choices. 84 Participants in the
2004 NPS were asked to choose among a list of factors that had influenced their career choice; an
overwhelming majority of the specialists who responded indicated that intellectual stimulation/challenge
(83.7%), the doctor-patient relationship (56.4%), and the influence of a mentor (42%) were the factors that
most influenced their selection of a career path.98 In the 2007 NPS, the presence of a mentor was also
noted as a more influential factor with regard to specialty selection for residents (Appendix 2, Table 11).
Approximately one quarter (26%) of Family Medicine residents and almost half (44%) of other medical
specialty residents reported that the influence of a mentor played a role in the selection of their specialty.
Although it was not a major factor for Family Medicine residents or other medical specialty residents, the
influence of a mentor ranked sixth for Family Medicine residents and fourth for other medical specialty
residents out of a total of 11 factors. Thus, a mentor can play a role in specialty selection, but more specific
and targeted questions would be required to accurately gauge and contextualize the role of mentors in
career decision-making. In the commentary submissions to the CCP there was general agreement that
formal career mentoring should develop hand-in-hand with any proposed changes to the medical
education system.
Lifestyle and income. In the CaRMS post-match survey for 2006, 12.2% of respondents indicated income
potential as an influential factor in their first choice of type of specialty or discipline, while 34.8% indicated
this as having had a moderate influence.99 Similarly, on the issue of educational debt and specialty prestige,
51.4% indicated that debt had “no influence” on their first choice of specialty, while 35.6% indicated that
the prestige of the specialty had a “minor” influence on their first choice.99 In the 2007 NPS, approximately
two thirds (64%) of all medical students had not accrued any debt on entering medical school. Thirty
percent of all medical students replied that they had accumulated between $0 and $60,000 of debt directly
related to their education on entering medical school, and 1% of medical students reported that they had
accrued a debt in excess of $60,000 on entering medical school (Appendix 2, Table 1).
Residents, on the other hand, had accrued some debt on entering their residency training program. Slightly
more than 20% of all residents had not accrued any debt, whereas almost equal numbers of residents had
accrued up to $60,000 or in excess of $60,000 in debt (32% and 33%, respectively) (Appendix 2, Table 2).

Despite the amount of educational debt anticipated by both medical students and residents to complete
their medical training, 84% of specialty residents who participated in the 2007 NPS stated that their
cumulative debt had no bearing on their choice of residency when they were asked about their choice of
specialty training area (Appendix 2, Table 7). By contrast, in the 2007 CAIR resident debt survey, 28% of
respondents agreed or strongly agreed that debt load affected their choice of discipline. Of this group, 33%
said that they chose a specialty residency over Family Medicine, and 20% had chosen a residency with the
potential to earn more after graduation. Although this and other articles in the literature review
demonstrated a strong link between level of indebtedness and students’ eventual choice of either a
primary or specialty care discipline,100,101,102,103,104 other literature and data support the assertion that
medical student career choice is not greatly influenced by debt or future income. 105,106,107,108,109,110 One
study noted in particular that other variables may be overlooked in the career choice literature, such as the
influence of the job market, the status or prestige of a specialty, educational experiences in medical school,
and family pressures/responsibilities. However, the issue of premature career decision-making may also be
influenced by factors that are not quite as evident. According to Hafferty,111 “a great deal of what is taught
and most of what is learned” in medical education occurs within what he calls the “hidden curriculum” of
medical school.
Although some commentators agreed that choosing a specialty prematurely may affect physician
satisfaction – which may or may not have a negative impact on the quality of health care – the
commentaries presented no evidentiary information to support this link (C1053) (C1012) (C1034). One
author commented that “whether PCDM leads to more or less satisfaction is not agreed on, [and the]
evidence is not clear – satisfaction is multi-factorial” (C1014). With regard to solutions, the commentary
authors again had diverse opinions. It was pointed out that “matching, and opportunities for Canadian
medical students are well balanced for choice and process. The matching process and choice of specialties
does not impact or influence a more informed career choice, which is the issue” [C1014]. Other authors
noted that solutions should reside at the undergraduate level and should be focused on mentoring,
shadowing and career counselling opportunities (C1009) (C1003) (C1053). Other recommendations
highlighted the need for more structural change, including delaying specialty choice, although there
continues to be strong agreement that training length should not increase.
A common denominator throughout all the commentaries was the importance of matching educational
objectives to societal needs. One author succinctly noted that “many medical students now focus their
education on the goal of matching to their desired specialty,” (C1035) while another authors states that
“there seems to be a tendency to overlook the need for a solid basic general knowledge in all areas of
medicine … I suspect this does not serve society very well” (C1032).
Family pressure and responsibilities. Certain factors may not be apparent career choice influences because
they fall outside of the formal curriculum. Family pressures and responsibilities are two examples that were
examined. On the basis of the demographic data collected in the 2007 NPS, the prevalence among medical
students and residents of (1) being married or living with a partner; (2) having children; or (3) expecting
children was examined. Nearly twice as many residents (59%) were married or living with a partner in
comparison with medical students (22%) (Appendix 2, Tables 12 and 13), and approximately one quarter
(24%) of residents reported having children (Appendix 2, Table 15).
To assess the potential influence of family pressures and responsibilities, cross-tabulations were run to
assess the impact of marriage or children on residents’ intent to practise in their current field of training
within 2 to 3 years of graduation (Appendix 2, Tables 18 and 19). Of the Family Medicine residents who
indicated an intention to practise as family physicians (general practitioners), there was only a marginal
difference between those residents who reported being single (81%) and those who reported being
married or living with a partner (79%). Findings were similar for other medical specialty residents. In view of

the limited number of responses, similar cross-tabulations for having children or expecting children could
not be reported. Given that nearly two thirds of all residents reported being married or living with a
partner, as well as the minor variance between those who reported being single and those who reported
being married or living with a partner, it appears that marriage does not influence residents’ career choices.
Barriers to switching career paths

Under the CCP, barriers to switching career paths have been defined as “constraints faced by residents in
switching career paths and by practising physicians in re-entering residency training.” Some key questions
that guided research under this theme, and that consequently framed the focus groups, commentaries and
survey questions, were:
 Is this a problem? Is it difficult for residents and practising physicians to switch career paths?
 How does the system’s flexibility affect future physicians’ career satisfaction?
 Does this issue have an impact on the quality of health care?
Career flexibility can be characterized at two levels:
 Post-residency: as a national physician resource strategy, for the purpose of adjusting the
specialty mix in the medical workforce by providing an opportunity for practising physicians to
return to residency training in a field that is needed in Canada or for physicians to pursue areas
of interest after a period of generalist practice and to return to training if they wish to change
career paths. This can be related to professional and/or personal satisfaction issues such as
career advancement opportunities, practice interests, and/or skills enhancement.
 In-residency (Switching): to provide opportunities for residents to alter career paths if they are
unhappy with their initial choice.
Post-Residency (Re-entry)
The issues of re-entry and switching are context-specific and differ among schools and provinces. A table of
re-entry policies for medical schools in Canada is given in Appendix 7. A scan of re-entry information and
data from schools provides the following results:
 The number of re-entry trainees has been consistent since 1994, averaging 73 trainees over the
last decade (Appendix 8).
 The number of re-entry positions provided varies on yearly basis, depending on the applicant pool
and on available funding after all regular Ministry-funded positions are filled in the CaRMS match (see
Appendix 6).112
 In most provinces, re-entry positions are tied to return-of-service requirements. Physicians who
are accepted into re-entry programs are normally expected to complete a return-to-service
agreement in an underserved area as identified by their provincial ministry of health. According
to the Report of the Working Group on the Common PGY-1, this return of service requirement
deters many physicians from taking advantage of re-entry opportunities.27
 Not all disciplines are designated as re-entry. Priority is given to providing specialty training in
areas of perceived projected physician resource need as determined by the provincial ministries
of health.
 National principles for crossovers and transfers were developed by the ACMC Standing
Committee on Postgraduate Medical Education for the purpose of facilitating career flexibility
within the parameters of provincial postgraduate resources, without undermining the
effectiveness of the CaRMS match. Medical schools across Canada have developed policies and
guidelines for the application of this process. Return-of-service requirements are the norm and
may have a long-term impact on the incentives for physicians to return to training.

The commentaries generally supported the perception that there are significant barriers to re-entering
training and that this difficulty is tied to provincial funding arrangements, the number of re-entry spots
available and provincial needs. One commentator noted that, in 2007, there were 14 government-funded
training positions for Dermatology in Canada and “virtually no possibility to change career paths by
transferring between programs and precious few re-entry options” (C1016). Difficulties with re-entry are
perceived to be jurisdictional with some provinces having more re-entry positions for physicians in practice
than others. Another commentator pointed out that the cause for the relatively low number of re-entries in
recent years is misleading, and may point less to the fact that re-entry is uncommon and more to the fact
that there are barriers to re-entry (C1059).
In-Residency [Switching]
Appendix 9 highlights the absolute number of trainees who switched per year (equalling an average of
120 per year over the period 2000–2007, and the number of trainees switching between major field
categories for each of the last five years. The 2000 CAIR Resident Switching Survey presented findings
which show that among respondents, the most significant factors perceived to be preventing residents
from changing specialties were:
 lack of a training spot to change in to (73.4% of respondents thought this a significant barrier);
 being unfamiliar with the process needed to accomplish a change (54.9%);
 fear of losing credit for training already completed (52.0%);
 fear of reprisal from faculty or supervisors (47.7%)
It is useful to note that this survey had a 38% response rate.113 The 2006 CaRMS post-match survey
question on changing matched residency disciplines indicated that over 86% of respondents do not plan to
change their matched discipline. The CCP survey showed that approximately four in ten residents (37%)
considered switching disciplines during their residency training.114 No significant differences were observed
between specialty medicine residents and Family Medicine residents. Almost one third (32%) of physicians
considered switching disciplines during their residency training. Family medicine physicians were
significantly more likely to consider switching disciplines than specialty medicine physicians. Of those
residents who switched disciplines during residency, respondents to the CCP survey indicated that more
than seven in ten (72%) were satisfied with the amount of credit they received for the training they had
already completed. Among physicians who switched disciplines during their residency, 74% were satisfied
with the amount of credit they received for the training they had already completed. Respondents were
also asked about their perceptions with regard to the barriers to switching disciplines during residency
training. The number of funded residency positions, followed by the ability to transfer credit for completed
training, were the largest barriers to switching disciplines during residency noted among all groups
surveyed.
At the First National Invitational Conference on Flexibility in Career Choice in Medicine (1997),
representatives from the RCPSC, CFPC and the FMLAC (now FMRAC, the Federation of Medical Regulatory
Authorities of Canada) recommended the adoption of “more generic and basic clinical training and no
subspecialty options so that residents would be more informed and better prepared to choose training in a
specialty or Family Medicine.” It was argued that such core training would also allow residents to “switch
training programs” if they decided they had made a mistake with their initial training choice.25 This support
for a common and basic PGY-1 was also repeated by subsequent CMA news articles which outlined benefits
for residents who wished to switch.56,115,116,117 The recently concluded CCP survey also mirrored this
recommendation. All groups surveyed, except medical students, say the current PGME system in Canada
produces too few generalists, and the majority of all physicians surveyed agreed that all first-year residents
should do a broad-based common PGY-1 such as a rotating internship (77%).

The concern that the current structure of the PGME system impedes residents’ ability to change career
paths (switch specialties) once they have commenced their residency training is not a new. As noted earlier,
system rigidity has primarily been attributed to changes in medical education training and licensure
requirements that occurred in 1993.7,118 Thurber and Buske have further elaborated on the lack of flexibility
and its impact in PGME:
We see the results of a tighter, more rigid post-M.D. training system in 1994, with fewer
physicians interrupting training to spend some time in practice and fewer physicians making
career path changes during training.118
National Principles for Crossovers and Transfers119 were created by the AFMC for the purpose of facilitating
career flexibility within the parameters of provincial postgraduate resources, without undermining the
effectiveness of the CaRMS match. Medical schools across Canada have developed policies and guidelines
to guide the application of this process. Although all the principles of the medical schools coincide with the
National Principles, program requirements vary among the universities.
In the commentaries, however, the transfer policies were criticized as “diverse ... complicated and too
secretive.” One barrier to flexibility arises because provincial funding is tied to the position rather than the
individual trainee, and because solutions might not be implemented easily – particularly because societal
health needs have to be considered by the provinces (C1055):
Methods of entry to residency training are often governed by provincially specific

requirements, limitations and expectations, especially those that are tightly bound to
funding provisions. As such, one uniform, pan-Canadian model, that includes all possible
entry options, may never be possible (C1005).
The complexity and variability of the health and education requirements are notable:
Resident training spots are funded by a combination of the health and education Ministry in
each province, and administered by the University where the residency training takes place.
The number of resident training spots funded is regulated by each province in coordination
with licensing bodies, provincial and national medical organizations and other organizations
contributing information regarding physician workforce needs. Because of this complex
system of administration, there is little flexibility within the resident training system for
individual resident changes in specialty or location of training.7
One commentary author noted that a negative effect may be attached to switching both in those provinces
in which funding is attached to the trainee and in those programs in which funding is tied to the program
itself. In the first instance, if a trainee elects to switch, then funding “moves along with the trainee, leaving
the initial program short one position for the duration of the trainee’s planned PGME program, [and] leaves
a deficit in the initial program” (C1013). In the second instance, “the accepting program would need to
identify funding for the transfer resident either by sacrificing a subsequent CaRMS position or through a
position created by the transfer of another resident out of the program” (C1013). In this way, funding can
limit the ability to switch. Notably, the “financial” and “logistical” difficulties are perceived as exceeding the
educational constraints (C1004) (C1006).
There is a definite lack of flexibility in the current system. Since the number of training slots
is determined by individual provincial ministries, transferring to another specialty” has to
occur within the province, which automatically places some restrictions on certain medical
schools (if there is only one medical school with residency programs in that province) and
certain residency programs (C1034).

Another commentator noted that the issue of switching “is difficult but less [so] than years ago” (C1045).
The impact of a resident switching has also been described as an area of concern by some who propose
that some specialties “may be penalized with by a reduction in entry positions to their specialty if they were
to accept people from other programs” (C1045). The financial impact of losing a resident
puts limits on the program for the remainder of the time the student would have spent in
the program. Not only does it leave a financial void but also removes a person on the call
schedule and puts more pressure on the other students (C1043).
No evidence was found on whether system inflexibility affects a physician’s future career satisfaction or the
quality of health care. The general perception was that there is a link, since “unhappy and unenthusiastic
physicians do not provide as good quality care as others who are engaged,” (C1039) but there was a lack of
data to support this perception. Another commentator noted that if residents are not happy in their chosen
career, “it affects their ability to deliver effective and efficient quality of care” (C1012).
Nevertheless, it is a strongly held belief in the Canadian medical education community that career
flexibility is an important component of ensuring a “productive and well-functioning health system that
meets the needs of all Canadians” (C1017). Flexibility recommendations put forward by some authors
include:
1. Creation of a formal transfer process both within and between centres, with a finite number
of supernumerary residency training positions to accommodate transfers (C1013).
2. Rethinking the way one views re-entry: “Re-entry is currently viewed as a pathway for those
unhappy with their current careers, as opposed to a true pathway of higher education,
where general experience is valued” (C1035).
3. Restoration of the general and broad nature of the basic clinical training year. This would
increase recognition among the specialties that require a broad-based first year and improve
flexibility (C1049).
4. Creation of a more formal career-counselling process for medical students to improve the
career decision-making process.
5. Increasing routes to re-entry.
6. Collaborating and engaging with provincial governments to determine a pan-Canadian
solution.
Quality postgraduate medical education

One of the key concerns of the Core Competency Project is the efficiency and effectiveness of the
postgraduate medical education system. How best can PGME in Canada be organized to ensure that it
performs optimally and meets the needs of students, residents and physicians – as well as, most
importantly, the health needs of Canadians? The questions that guided our research under this theme
were:
 Does the large number of PGME entry points have an impact on medical students’ selection of
the type and number of electives they pursue in their undergraduate years?
 Is the current PGME structure optimally designed?
 Is there an adequate balance between generalism and specialization in training and in practice
to properly meet societal needs?
 How does the current PGME structure affect the quality of health care?
According to the 1996 Royal College’s Maudsley Report, “the primary objective of specialist postgraduate
medical education is to prepare an appropriate number and mix of consultant physicians and surgeons,
with the requisite knowledge, skills and attitudes to meet the needs of Canadian society.”1 The link

between the medical school environment and the health care system has become even closer with the
increasing specialization in PGME (Figure 1), the explosive growth of the knowledge base for medical
practice, and changing demographic and social conditions in Canada. The perception has been that the
medical education system in Canada educates through an increasingly steep pyramid, in which
specialization and subspecialization have become the norm. There is also a belief that a premature
emphasis on specialization in medical education may interfere with the educational experience of
undergraduate and postgraduate medical trainees by placing pressure on students to decide on a preferred
residency program early in medical school – which could, in effect, have an impact on the educational goals
of the program itself.20 Should medical education in Canada be transformed to meet these changing
contextual environments? Key issues that emerged throughout the research phase of this report are:
 specialization in PGME
 a common foundation of training in PGME
 number of entry points into PGME
 level of satisfaction and preparation for future practice.
These themes will be developed in the following discussion.
The Generalist-Specialist Balance in the PGME “Pipeline”

The proportion of “exiting” trainees in Family Medicine and other broad-based specialties has remained
steady, averaging just below 40% over a 10-year period.120 The CaRMS post-match surveys also show that
the quota of positions offered into residency training had steadily kept up with the number of graduates
(Appendix 6). The literature outlines several determinants of generalist career intentions spanning
educational, economic, social and other factors. These include physician compensation policies, exposure to
family physician role models, the timing of career choice in Canada, the medical school admissions process
and required clinical training.85,109,121,122,123,124,125
Would a period of foundational training ensure that societal health needs are met by providing physicians
with a common base of core training regardless of their eventual choice of subspecialty? The opinion of
commentators as to where exactly in the medical education system the balance between generalism and
specialization should be implemented and how this can be done varied greatly. One commentator noted:
The system is seen as “punishing” [medical students] for broadening their experiences in
medical school, as, if they apply to a competitive specialty, they may be seen as … less
competitive, more scattered candidate[s], [compared] to those who have done a narrow
choice of electives. (C1033)
On the other hand, another commentator noted:
The postgraduate medical education should be designed to ensure that the trainees get a
broad exposure to different specialties, particularly in the early years of training (C1031).
Other comments included the following:
[T]he large number of PGME entry points and limited number of positions in some of the
very competitive programs does impact on the type and number of electives that medical
students pursue during their UG years (C1017).
Because of the competitive nature of some postgraduate programs, students concentrate
their electives in single areas … [T]he ultimate net result may be physicians who are
mismatched to their career choice and who lack a broad-based clinical foundation (C1003).

Other commentary authors attempted to link the “generalism” in the medical education debate to societal
and health care needs:
The current postgraduate medical education program has affected health care by funneling
individuals to subspecialties and partially diminishing the value of a generalist specialist
(C1019)
Taking this into account, however, others have noted that
[a]chieving balance requires content as well as structure. Changing the structure will have
no impact on balancing “generalism” and specialism unless the content to fill that structure
is carefully designed to meet that goal (C1004).
Similarly, in the CCP survey, approximately three in five medical leaders (more than in any other survey
group) agreed that the Canadian medical education system is effective at meeting the needs of those it
serves, while one in five residents (more than any other group) felt that no change was needed to the
current system.126 The Royal College Education Committee, at its 2006 conjoint meeting with the Deans of
Postgraduate Medical Education, sought to arrive at a mutual understanding on the issue of generalism in
Canada. A series of definitions was presented to the conjoint committee for consideration. After
deliberating, participants agreed that the issue is context driven and that the definition of generalism will
vary according to numerous factors, which include but are not limited to the region of practice and the area
of specialization. Therefore, participants were unenthusiastic about the idea of presenting a single, all-
encompassing definition of generalism.
Foundational training
All specialists, regardless of their discipline, require a common foundation of knowledge, skills, and
attitudes. This foundation, established during undergraduate medical education, must be maintained and
enhanced during the postgraduate period and throughout the professional career of the physician.127
The objective is the acquisition of the knowledge, skills and attitudes basic to the practice of the discipline
and preparatory to further training. In 1993 Liebelt and colleagues evaluated a large US pediatric residency
program to determine whether the program was providing quality education and relevant training for
pediatricians. They concluded that there was support for the concept of broad education in general
pediatrics for residents, regardless of future career choice.128 The Residency Review Committee of the
program noted:
Programs must provide a broad educational experience in pediatrics which will prepare the
resident to function as a specialist capable of providing comprehensive patient care.
Training must involve all aspects of human growth and development from conception
through fetal life, infancy, childhood, adolescence and young adulthood and must include
both preventive and therapeutic pediatrics.128
Finding an optimal balance between generalists and specialists is of vital importance in meeting societal
needs. The Maudsley Report (1996) stated:
The development and maintenance of a common foundation and the practice of specialized
medicine are complementary rather than mutually exclusive … The Task Force believes
there is a need to emphasize principles of generalism during the residency, with a
progression from generalism to specialism during the residency period. A base of general
knowledge, skills, and attitudes is essential for all specialists to be taught and reinforced
throughout the entire residency and also maintained throughout the entire career.1

In 1998, the Royal College’s Langer Report advocated the development of a core training model and
detailed the potential advantages and disadvantages of such a model, including “consistency of
development of training programs across disciplines” and “improved flexibility for career choice among
trainees.”21 The report noted that core training at the beginning of specialty training in Medicine, Surgery,
Laboratory Medicine, Imaging, Pediatrics, Obstetrics and Gynecology, and Population Health specialties
will provide the general experience required to meet the educational needs common to
major disciplines. In addition, those general competencies expected of all specialists will be
included in the objectives throughout the residency.21
Further, the majority of Family Medicine and Royal College physicians surveyed under the CCP survey
agreed that all first-year residents should do a broad-based common PGY-1 year akin to a rotating
internship (77%).129 A similar theme emerged in the commentaries. Although participants commented that
the movement toward super-specialization is in response to the public’s need for high-quality care, the
perception is that this narrow focus may have a negative impact on the care of the patient as a whole.
Commentators agreed that there should be some commonality of training within and among all specialties,
as this would allow for more exposure to various disciplines and would better equip a trainee who wishes
to switch.
A common, core period of training and the question of finding an appropriate balance between the
generalist and specialist perspective in medical education were also explored to some extent by the Royal
College Committee on Specialties in its Principles of Decision-Making document (2004), and by the
Canadian Medical Association, the Ontario Medical Association, the Canadian Medical Forum and the Task
Force on Generalism in Undergraduate Medical Education (University of Ottawa).20,22,24,26,27
Yet the issue of relinquishing “ownership” of the basic core years was a highlighted concern in the
commentaries. As one author wrote, “at present the core years are designed by each program to give the
best experience they feel they can to their residents prior [to further specialized training in that specialty+”
[C1018]. Many authors examined the concept of generalism more narrowly, within their own specialty, and
were satisfied overall with the structure and format of training, noting that some form of foundational
training already exists within their own specialty (C1047)(C1003), although not among groups of specialties.
Yet another author pointed out that the “generalism” debate is properly placed under the “health care”
and “manpower” umbrella (C1048) and that implementing a period of core training may serve to lengthen
training (C1048)(C1036).
The desire to strike an appropriate balance between generalism and specialism is not new. However, as
Turnbull and colleagues have noted:
In providing the best health care for our patients and community, we must stop thinking of
generalism and specialization as two opposing dichotomies, but consider them in a
spectrum, with each uniquely contributing to the integrated delivery of health care … For
optimal health care to be provided, a critical balance between generalism and specialization
is needed. Neither can exist in isolation.130
A concern with meeting the overall health care needs of diverse communities was at the forefront of the
majority of commentaries on generalism. Commentaries also suggested that generalism in medicine has to
be viewed longitudinally. That is, solutions must encompass both the undergraduate and the postgraduate
years of training. Proposed options included valuing the teaching and experience of the generalist division
[C1045], increasing the number of generalist role models in the training system (C1007), changing
remuneration systems [C1007], and limiting the number and length of electives in one specialty (C1014).

PGY-1 entry points

Reports and correspondence from the undergraduate and postgraduate standing committees of the AFMC,
the Canadian Medical Forum (CMF) and some commentators to the CCP suggest that the issue of early
career decision-making faced by medical students is compounded by the large number of PGY-1 entry
points, which compel a narrowing of electives by students early in medical school to allow them to match to
a preferred specialty. In its 2004 report, the CMF made the following recommendation:
The Committee on Specialties of the RCPSC should evaluate the routes to entry into RCPSC
training programs, as there is uncertainty about the rationale for the entry levels for certain
specialties and the impact of 32 different sub-specialty programs on early career decision-
making.27
The AFMC Standing Committee on PGME, in their 2006 correspondence to the Director of Education of the
RCPSC, generally supported the idea of reduced entry streams but expressed the view that such any such
change should be based on sound educational principles. The Standing Committee recommended “broad
consultation with government to ensure that the core competency model is congruent with plans for
reinforcing generalism in Canada.”131 However, consultations, in particular the focus group consultations,
rejected this idea of reduced entry points into PGME.
Level of satisfaction and preparation for future practice

The results relevant to the Core Competency Project from the 2007 NPS data and from the CCP survey were
examined. In particular, data for the level of satisfaction with residency training programs and preparation
for future practice were extracted and analyzed. When asked about the level of satisfaction with their
residency program in the CCP survey, both Family Medicine residents and other specialty medicine
residents reported high levels of satisfaction - Eight-two percent of all residents indicated that they were
either satisfied (50%) or very satisfied (32%) with their residency training program. This stands in contrast
with the 4% of all residents who indicated that they were dissatisfied (3%) or very dissatisfied (1%) with
their residency training program. This CCP survey also indicated a high satisfaction rate with career choice:
96% of medical students surveyed and 90% of residents were very satisfied or somewhat satisfied with the
discipline they had chosen to pursue (Figures 2 and 3).
Other specialty medicine residents were asked to what extent their residency training program had
prepared them for future practice and what skills they were lacking. Eighty percent reported that residency
training had prepared them for future practice, as opposed to the 3% who reported that residency training
had not prepared them (Appendix 2, Table 24). Fourteen percent reported that they were not sure if
residency training had prepared them for future practice and the remaining 3% failed to provide a response
(Appendix 2, Table 24). Three aggregate categories132 of skills were identified as lacking in residency
training. One quarter (25%) of specialty medicine residents reported that procedural skills was an area they
considered to be lacking; 14% reported a lack of exposure to clinics and health care outside of hospitals;
and 9% reported lacking exposure to office and business management (Appendix 2, Table 25).
Overall, the majority of medical students and residents (in Family Medicine and specialty medicine) felt that
their level of satisfaction with residency training was high and that their training had prepared them well for
future practice in their communities.


Section 6 – Discussion and Analysis

The qualitative review and analysis of focus group and commentary data, the Core Competencies Project
(CCP) survey findings and the review of the National Physician Survey (NPS) results for 2007–2008 have
further substantiated the implications that were presented in the Interim Report. In some cases, however,
given the wide diversity of responses, it was not feasible to generalize the findings that were derived from
the focus group discussions and invited commentaries. Nevertheless, common themes have been identified
across all research areas for this project.
Timing of career choice and satisfaction with choice
Overall conclusion
Although there is a widespread belief that the postgraduate medical education (PGME) system has a
negative impact on some medical students in their decision-making process, data from the 2007 NPS, the
CCP survey and CaRMS post-match surveys indicate that a large majority of medical students, residents and
practising physicians felt prepared for residency training and are satisfied with their career choice.
Furthermore, stakeholders identified the stressors of the process (such as a competitive match) as
inevitable, regardless of when they are scheduled. There was no evidence that mandating fewer CaRMS
entry disciplines would address the issues identified. Finally, stakeholders reported that many of these
concerns would be moot if the system allowed changes to be made between disciplines more easily (see
Switching and Re-entry, below).
Discussion and analysis

Concerns about premature career decision-making and the timing of the postgraduate medical education
(PGME) admissions process were expressed in the literature, in invited commentaries and in
correspondence with the CCP. However, the evidence characterizing the extent to which premature
decision-making is a problem was conflicting.
Commentary authors were consistent in their view that medical students choose a specialty at an early
stage in their training with very little opportunity for broad exposure to all aspects of medicine. The
Working Group on the Common PGY-1 and the AFMC Standing Committees on Postgraduate and
Undergraduate Education have also alluded to this factor in their reports and correspondence with the
Royal College. 27,44 Judging from the commentaries, however, it seems that although there was consensus
that the issue of premature career choice is important, there was no consensus as to its causes or solutions.
Authors noted the career choice anxiety arising from the competitive nature of the process and the limited
number of opportunities to enter certain specialties, as well as the tension between student choice and
societal need as reflected in government control over funding issues. At the same time, however, it was
pointed out that measures to offset premature career decision-making, such as delaying the timing of
specialty selection or increased emphasis on common foundational training would not remove the inherent
stresses of career decision-making.
The opinions received by the CCP raised doubt as to whether common perceptions of the negative impact
of the timing of career choice in medical school do in fact reflect the reality that medical students currently
face. The evidence derived from the focus groups, commentaries and institutional data reports yields no
consensus that premature career decision-making presents a significant, systemic problem for medical
students. In the 2007 NPS, medical students were asked, “To what extent do you agree that your medical
training program has prepared you (or will prepare you) to select a residency training program?133”

(Appendix 2, Table 20). Sixty-one percent of all medical students either agreed or strongly agreed that they
felt prepared for residency training, as compared with the 15% who disagreed or strongly disagreed and the
21% who were neutral about their level of preparation during medical school. Other specialty medicine
residents were asked, “Within 2–3 years of completing your residency, do you plan to practise in the field in
which you are currently training?”134 (Appendix 2, Table 21). Further, Family Medicine residents were
asked, “Over the next 2–3 years, once you complete your Family residency training, do you plan to practise
as a Family Physician (General Practitioner)?”135 (Appendix 2, Table 22). Eight-one percent of Family
Medicine residents indicated an intention to practise as a Family Physician (General Practitioner), and 85%
of other specialty medicine residents reported an intention to practise in their current field of training.
Therefore, according to the 2007 NPS, a large proportion of medical students agreed that they felt prepared
for residency training, and Family Medicine and specialty medicine residents indicated an intention to
practise in the field they had chosen.
In addition to the timing of career choice, other key systemic issues were examined in the research and
consultation phase of the CCP; these were the varied influences on student career choice of educational
debt, the medical school environment, role models and electives.
The literature identified in the Interim Report was equivocal as to the impact of student debt on premature
career decision-making. In the current phase of the CCP, the role of educational debt was assessed in light
of data from the 2007 NPS regarding the amount of educational debt acquired upon entering medical
school, anticipated levels of educational debt upon completion of medical training, and potential options to
address educational debt accrued during medical training. 45% and 36% of medical students and residents
respectively, anticipate having an accrued debt of $60,000 or more upon completion of medical training
(Appendix 2, Table 5). Medical students who reported in the 2007 NPS survey an anticipated debt load on
completion of medical training were presented with a list of options to address this situation. Thirty-three
percent of respondents indicated an intention to practise where they were offered a financial recruitment
incentive; 21% reported an intention to practise as a locum tenens,136 and approximately one quarter (23%)
indicated that they intended to choose a specialty with a high earning potential. However, half of medical
students (50%) stated that they did not intend to make use of any of the options listed to repay their
educational debt.
Despite the amount of educational debt anticipated by both medical students and residents to complete
their medical training, 81% of all residents who responded to the NPS survey reported that their cumulative
debt had no bearing on their choice of discipline (Appendix 2, Table 7). Results of the 2007 CAIR resident
debt survey, however, suggest that “debt load is a factor affecting a significant number of residents” as “3
out of 10 respondents (28%) agree or strongly agree that debt load affected their choice of residency
training discipline.”137
The undergraduate curriculum performs a critical role in providing students with the clinical and academic
exposure needed to make informed decisions about a choice of career path. As Table 4 shows, medical
students who participated in the 2007 NPS survey expressed, overall, a high level of satisfaction with their
exposure to medical specialties. In the CCP survey, although approximately half (51%) of medical students
reported that their career choice was difficult, and 77% of program directors and 82% of medical leaders
reported that the experience of medical students in choosing a career discipline was somewhat or very
difficult, all respondents reported a relatively high level of satisfaction. Seventy-two percent of medical
students, 90% of residents and 92% of physicians reported being satisfied with their career choice. Seventy-
seven percent of program directors and 80% of medical leaders also believed that contemporary medical
students were very or somewhat satisfied with their career choice. These data are further reinforced by
responses from physicians and medical leaders. According to program directors, about one in seven

residents (15%) consider switching disciplines, while medical leaders believe that about one in six residents
(17%) consider switching disciplines.
Switching and re-entry
Overall conclusion
No data were found on whether system inflexibility affects physicians’ future career satisfaction or the
quality of health care. However, stakeholders generally held that a system that allowed greater flexibility
for changing disciplines during and after initial residency would benefit the profession and patient care by
ensuring that physicians are best matched to their roles in medicine. Many of the identified barriers to
system flexibility, such as government funding, are outside the jurisdiction of the Colleges. A notable
exception lies in the standards for credit for previous training, which the Colleges oversee.

There was a general consensus throughout the focus groups and commentaries that switching is most
difficult (1) across provinces and schools (because of funding requirements); and (2) across specialties that
share little or no common training. With regard to re-entry, the commentaries reflected a general
consensus that re-entry is uncommon, given the financial impact physicians face on returning to training,
the low availability of re-entry training positions, and the fact that most provincial re-entry requirements
are tied to return-of-service agreements. All respondents to the CCP survey indicated that the limited
availability of funded residency positions presents the largest barrier to switching disciplines during
residency (Table 5). In the focus groups and commentaries it was noted that clinical service could also
present a barrier to switching specialties, as a loss of a resident would mean losing the coverage her or she
provides.
A common theme throughout the commentaries was the complexity and variability of funding and transfer
requirements across schools and provinces. The linking of provincial funding requirements to the position
rather than the trainee was one of the primary barriers to flexibility cited by stakeholders, since this affects
both a residents’ ability to switch (since funding is not transferable) and the number of positions created by
provinces to fulfill provincial health care needs. Transfers can be impeded both in provinces where funding
is attached to the trainee and in programs with tied funding. A common perception in the commentaries
was that it can be easier to transfer within a university rather than across schools and provinces.
With regard to re-entry, focus group and commentary participants noted that re-entry is uncommon
because of the financial impact that physicians face on returning to training, the limited availability of re-
entry training positions, and the return-to-service agreements that physicians are expected to undertake
in areas identified as underserved by their provincial health ministry.

TABLE 5 REPORTED BARRIERS TO SWITCHING DISCIPLINES IN RESIDENCY

% of responses
All All FM Medical Medical Program RC Specialty
Barrier physicians residents residents FPs leaders students directors physicians residents
Ability to transfer credit for
completed training 46 40 37 45 44 56 51 48 45
Fear of being isolated 16 19 15 13 25 25 20 18 25
Length of training 27 26 29 33 22 16 27 22 21
Location of available position 32 28 27 34 35 36 45 31 30
Number of funded residency
positions 64 55 54 63 89 79 83 65 57
Resistance from postgraduate
deans 6 10 8 5 10 8 12 6 14
Resistance from program
directors 26 23 22 24 31 54 21 27 24
Resistance from other
residents 2 2 1 2 6 6 3 3 4
Satisfied with present
choice/decided against
switching <1 1 1 <1 0 0 0 <1 <1
Uncertainly/indecision about
career choices/expectations <1 1 1 <1 0 0 1 <1 <1
Other 6 5 6 6 10 1 6 6 2
Don’t know 17 20 22 18 3 4 3 17 16
No barriers 2 4 4 1 0 0 <1 2 5
Data source: 2008 CCP survey
Evidence suggests that although some constraints exist, it may be easier to switch disciplines or return to
training now than it was a few years ago. The number of physicians who consider switching appears to be
somewhat stable over multiple generations: 32% of physicians and 37% of residents reported in the CCP
survey that they considered switching during residency (Figures 4 and 5). This is consistent with the 2000
CAIR Resident Switching Survey, where more than one-third of respondents (36.1%) said they were
considering or had considered changing their specialty.138 Of the residents and physicians in the CCP
survey who reported switching, almost three quarters of those who switched during residency were
satisfied with the amount of credit given for training already completed (72% and 74%, respectively).
A common theme in the commentaries was the insistence of program directors that they would rather
cope with switching than have unhappy residents who are dissatisfied with their chosen career path.
Although no data were found on whether system inflexibility affects a physician’s future career satisfaction
and subsequently the quality of health care, this link was a widely held belief.


The effectiveness of the PGME system in responding to the needs of trainees

and society
Overall conclusion
In general, there is a high degree of support for the current structure and function of the Canadian PGME
system across a breadth of stakeholders. Beyond this, PGME stakeholders held diverse opinions about
future enhancements to the system. Contributors to the CCP hold the principle of building on a broad base
of “general competencies” to be a central tenet of Canadian training, and an essential ingredient in
preparation for effective practice. Most stakeholders believe that the PGME system needs to produce more
“generalist specialists” than it does now. At the same time, widespread concerns about hyper-specialization
contrast with passionate beliefs and data about the necessity of focused expertise.

The Core Competency Project has examined the efficiency and effectiveness of the PGME system in Canada
with a view to identifying ways in which it can be optimized to meet the needs of students, residents,
physicians and the general public. It is generally believed that high-quality PGME should expose medical
students to a breadth of available options to facilitate informed career choices and to build a foundation of
common knowledge regardless of the career path eventually chosen. In addition, the need to align the
system to societal needs by ensuring an appropriate mix of abilities among graduates is widely accepted.
The latter issue has often been a springboard for a debate on generalism in Canadian medical education.
The present report builds on the examination of generalism provided in the CCP Interim Report. Medical
education in Canada progresses through an increasingly steep pyramid, and over the years there has been a
trend toward greater specialization (see Figure 1) and the selection of specialist rather than generalist
careers. This perception of subspecialization was noted in the commentaries as well, and was accompanied
by a recommendation to work toward greater commonality of training within and among all specialties. A
recurring theme in the commentaries was the impression that graduates are too specialized and by that
token less able to meet the needs of their patients, and that achieving an optimal mix between generalists
and specialists is a necessary response to societal health care needs. Data from CAPER, CaRMS, the CCP
survey and the 2007 NPS survey all informed these discussions.
In the commentary data and the CCP survey data, strong opinions were expressed as to whether the
Canadian medical education system is effective at meeting the needs of those it serves. The general view of
commentators was that residents risk becoming too specialized, and that this trend, while satisfying the
public’s need for expert care, may compromise medical residents’ exposure to a wide range of disciplines
and their understanding of the patient as a “whole.”
With the exception of medical students, all groups surveyed in the course of the CCP expressed general
agreement that the current PGME system in Canada produces too few generalists (Table 6). Medical
students did agree that there should be a stronger and earlier emphasis on broad-based training. Some
program directors, however, expressed reluctance to give up “ownership” of the basic core years, which
they preferred to shape to the particular needs of their specialty. Moreover, many authors examined the
concept of “generalism” quite narrowly, within their own specialty, and were generally satisfied with the
structure and format of training – noting that some form of foundational training already exists within their
discipline. Others expressed the reservation that increased foundational or common training could result in
a lengthening of the training period.

TABLE 6 VIEWS OF THE CURRENT POSTGRADUATE MEDICAL EDUCATION SYSTEM

% of responses
All All FM Medical Medical RC Program Specialty
residents physicians residents FPs leaders students physicians directors residents
Put a stronger/earlier emphasis 33 38 39 41 28 37 36 28 24
on a broad-based generalist
PGME produces too few 44 43 46 48 31 35 38 37 41
generalists
PGME supports a balance of 18 14 12 9 27 20 19 29 27
generalists and specialists
PGME produces too few 3 3 3 2 9 6 5 4 3
specialists
Put a stronger/earlier emphasis 2 1 0 1 4 2 2 3 6
on subspecialty curriculum
Data source: 2008 CCP survey
The need to meet the overall health care needs of diverse communities was a prominent theme in the
commentaries on generalism. Also emphasized was the need to view generalism in medicine has to be
viewed longitudinally,” such that solutions must encompassed both the undergraduate and postgraduate
years.
Although the proportion of Canadian medical graduates who selected Family Medicine as their first choice
declined from over 40% in the early 1990s to 26% in 2004, more recently interest in this discipline has been
steadily increasing to the point where Family Medicine represented 31% of matches in the 2008 CaRMS
first iteration.120
The 2007 NPS survey analyzed three factors related to quality of current PGME structure: level of
satisfaction with residency programs; preparation for future practice; and degree of balance in residency
training. In spite of the data showing a trend toward overspecialization, respondents were generally of the
opinion that the Canadian PGME system meets the definition of quality. Eighty-two percent of all residents
in the NPS indicated that they were either satisfied or very satisfied with their residency training program
(Table 7). The findings of the CCP survey showed that more than three in five medical leaders consider the
Canadian medical education system to meet the needs of those it serves, while 37% of physicians disagreed
with this statement (Figure 6).
TABLE 7: LEVEL OF SATISFACTION WITH RESIDENCY TRAINING PROGRAM

% of responses
Level of satisfaction Family Medicine Other specialty medicine All residents
(n = 282) (n = 451) (n = 733)
Very dissatisfied 3.5 0.7 0.7
Dissatisfied 2.1 3.8 3.1
Neutral 9.6 10.4 10.1
Satisfied 54.3 46.8 49.7
Very satisfied 27.3 35 32.1
No response 6.0 3.3 4.4
Total 100 100 100
Data source: NPS 2007

Recommendations proposed to improve the system were varied. Among the medical students, program
directors and medical leaders surveyed, creating more residency positions was ranked the most important
improvement needed by Canada’s residency education system, while specialty medical residents ranked a
common PGY-1 as the most important change and family physicians proposed more flexibility in changing
programs or specialties.
The commentaries provided a rich and diverse set of opinions that best reflect the implementation issues
associated with seeking a level of balance within residency training. Authors expressed the view that an
understanding of broad areas of medicine may be an unrealistic objective. They emphasized that while
there needs to be some generalism and commonality of training among disciplines – to better equip
physicians and facilitate transfer between specialties – this should not be pursued at the expense of an
extra year of training. Some commentaries further noted that societal health care needs are increasingly
requiring a supply of physicians and surgeons who are specialized within narrow areas of medicine,
suggesting that the concept of an appropriate “mix” of specialists and generalists may actually go against
this trend in health care. Although the implications of this analysis (particularly with respect to the
commentary submissions) mirror those presented in the Interim Report, the CCP and NPS surveys provided
evidence that the current PGME system effectively meets the health care needs of the public and satisfies
the definition of a quality PGME system.

Competency-Based Education
Competency-based education (CBE) represents a paradigm shift in how education, training and
assessment is conceived and implemented in all professional domains, at all levels of education and
training and in jurisdictions worldwide. It represents a shift from the structure and process-based
system that has defined the training experience in education to an outcome-driven educational
139
system focused on knowledge application rather than knowledge acquisition. Given the exponential
growth in science, technology and expertise, CBE was highlighted as a promising avenue for exploring
how medical education outcomes can be applied to the curriculum to best meet the needs of its society.
The systematic review on competency-based education was undertaken to answer the research question
“How is CBE defined within the context of medical education?” Our objective was to identify and
synthesize evidence of published and unpublished definitions of CBE within the field of medical
education in order to derive a definition of CBE that is universally-acceptable or at best can improve our
understanding of the concept. 134 reports satisfied all inclusion criteria and formed the basis for our
analysis.
Four major themes emerged during our coding – 1) Organizing framework of CBE 2) Rationale 3) Contrast
with time-based education 4) Components of CBE. In medical education, the conceptualization and
application of CBE diverges, depending on the specialties, accrediting institutions, academic institutions,
professional bodies and jurisdictions within which it is used. There are similar challenges with regard to
the perceived benefits of a CBE approach. Some sources highlight the significance of CBE towards
improving the efficiency and effectiveness of residency training while some are unsure as to whether it
represents something more than a “theoretical construct” or an “educational fad”. Preliminary
conclusions arrived at are, that a definition of CBE must include:
1) An identification and standardization of outcomes

2) Demonstration of these outcomes
3) Assessment to evaluate progression towards achievement of outcomes
4) A process that is trainee and patient-centered
CBE’s promise is as an approach that realigns medical education systems to: focus on outcomes and
societal needs, move away from strict time-based credentialing and efficiently rationalize training while
ensuring graduate competence. The implementation of CBE across the spectrum of medical education is
therefore a strategy that is worthy of exploration in greater detail to understand whether it can
contribute to meeting societal needs in Canada.

Section 7: Directions for the Colleges

Preamble
st
The following are offered as directions for further enhancement of the Canadian PGME system for the 21
century. These recommendations are derived from the data, the consultations, the deliberations, and the
feedback of key stakeholders of this project. While the CCP revealed a diversity of opinions in the medical
community on many issues, the following are held as the balanced and reasoned way forward for the issues
the project was commissioned to address.
In proposing these directions, four principles of education are implicit in the current philosophy of Canadian
PGME:
1. That medical education must be designed a system to meet the health care needs of the society it
serves;
2. That medical education must strive for excellence in its design in function, to ensure the greatest
possible competence of the physicians produced;
3. That medical education must be a system that enables a progression of expertise and focus from
undergraduate education to foundational postgraduate education to generalist specialist training to
subspecialty training to focused scope of practice;
4. That medical education must incorporate the imperative of lifelong learning, and that competence is
not a static phenomenon that does not change at the end of PGME.
The timing of career choice and satisfaction with choice

1. That the Colleges disseminate its findings of high satisfaction with career choices among physicians at
all stages of their career in order to clarify the perception that students are extensively unhappy with
the system.
2. That the Colleges reject calls to impose a reduction in the number of CaRMS entry specialties for the
purpose of assisting career choice. The evidence does not suggest that this would be beneficial, and
in fact it may be harmful.
3. That the Colleges not support calls to delay the timing of the PGY1 match. Given the balance of
opinion that this would not be beneficial and may prolong training.
4. That in order to address broader system issues in career choice by medical students, the Colleges
should facilitate the creation of a Canadian Medical Careers Forum (CMCF). Engaging partners in
Canadian medical education, the CMCF would be a forum to discuss directions for the
implementation of improved career decision-making in medicine and to address recurring and
emerging issues in career decision-making including by the following means:
a. Career Mentoring Initiative: That the RCPSC and the CFPC, in collaboration with the AFMC,
Canadian faculties of medicine, CaRMS, CFMS, FMRQ and other key stakeholders, review and
develop best practices for mentorship opportunities;
b. Career Information Initiative: That CMCF stakeholders undertake to assemble and disseminate
greater information to assist physicians in career choice decisions, including descriptions of
specialties, their lifestyles, and job prospects.
5. Encouraging “broad experiences” in early training may benefit physician practice and patient care
over the span of a career. Therefore the Colleges, through the proposed CMCF, could undertake
initiatives that would pursue this goal by:

a. Encouraging a breadth of electives: That the CMCF evaluate the impact of the recent AFMC Joint
Undergraduate and Postgraduate Medical Education Committee’s elective diversity initiative;
b. Encouraging a breadth of experience: That the CMCF explore and implement enhanced residency
selection criteria that emphasize a broad base of medical student experience.
Switching and re-entry

1. That the Colleges articulate a policy supporting flexibility in PGME, wherever it produces a net benefit
to the medical education and health care systems.
2. That the RCPSC and the CFPC, in collaboration with key partners, initiate a process to address
systemic recurring issues in post-MD career choice, including re-entry, practice enhancement, and
retention in practice.
3. That to accommodate the switching process the Royal College promote the creation of a national
registry for collecting data on opportunities for transfer across Canada to ensure that residents
wanting to switch and physicians wanting to re-enter the system are fully aware of all residency
openings;
4. That the RCPSC and the CFPC advocate to provincial governments, in collaboration with key partners,
a review of funding schemes and return-of-service agreements to better take into account the needs
of Canadian physicians wanting to switch disciplines or re-enter training;
5. That the RCPSC, through its specialty committees, Credentials Committee, and the policies of the
Office of Education, encourage greater flexibility through the granting of credit for training
completed.
The effectiveness of the PGME system in responding to the needs of trainees

and society
1. That the Royal College and the CFPC, in collaboration with key partners, engage in an ongoing
dialogue on the subspecialist–generalist-specialist mix to best meet the needs of Canadians.
2. That the Royal College promote the acquisition of a broad base of competencies in the early years of
PGME, in order to promote holistic patient care and prepare for lifelong learning in practice.
3. That the Royal College reject calls to impose a “trunk and branch” system on the disciplines
recognized by the RCPSC. Instead, the College should endorse a policy of defining disciplines as a
logical progression of expertise from training (e.g., from entry specialty to subspecialty to further
areas of focused competence).
4. That the Royal College Committee on Specialties further enhance the criteria and categories for
specialty recognition to meet the health care needs of Canadians and the medical profession. Such
criteria and categories should be designed to promote flexibility, lifelong learning, retention in
practice and the development of new areas of expertise without harming generalist-specialties. This
may involve the College moving to grant new designations beyond the FRCPC/SC.
5. That the Royal College, in collaboration with key partners, explore opportunities for incorporating
competency-based education in residency training and across the spectrum of medical education.
st
This would ensure that the 21 century PGME system is focused squarely on meeting societal needs
as the primary goal of training. Implementing any such change would conceivably take many years
and require a coordinated, resourced, collaborative approach.

APPENDIX 1 – GLOSSARY
Barriers to switching disciplines (Inflexibility)
Constraints faced by residents in switching career paths and by practising physicians in re-entering
residency training.
Core training
As defined by the RCPSC Committee on Specialties (COS), core training is the initial period of general
clinical training common to all trainees in a discipline. The objective is the acquisition of the knowledge,
skills and attitudes basic to the practice of the discipline and preparatory to further training.
Core Competency Project (CCP)

A project of the RCPSC and the CFPC that aims, first, to identify, define, and analyze the factors that
contribute to the major structural issues of postgraduate medical education (PGME) in Canada and,
second, to recommend options for addressing them. The CCP will seek to ensure high-quality residency
education that capitalizes on the breadth of knowledge and experience that is required of Canadian
specialists; to ensure optimal flexibility in PGME to meet the needs of residents who want to make
changes in their choice of specialty and of practising physicians who wish to alter career paths; and to
examine ways in which the system can provide medical students with optimal time to make an informed
decision about their career path.
Generalism
An enhanced skill set that builds on a foundational specialty or a defined set of competencies that is
fundamentally required at the outset of further specialization. Factors that affect generalism include
educational program requirements and practice environment (service delivery patterns and resource
allocation). Potential skill sets are shaped by these two factors (as discussed by the Conjoint Meeting of
the RCPSC and the Standing Committee on PGME, 17 November 2006).
Generalist curriculum (Canada)

Broad-based training that encompasses a logical progression in training from breadth to focused
competencies required for Canadian specialist practice.
Generalist curriculum (USA)

In the United States, training that promotes the US-based primary care disciplines (Family Medicine,
General Internal Medicine and Pediatrics).
PGME Entry Point

Admission into a discipline of the PGME system. Currently, there are a total of 32 CaRMS entry positions.
Premature career decision-making (early career decision-making)

A medical student’s commitment to a specific career path without adequate exposure to the breadth of
available options.
Quality postgraduate medical education (PGME)

Best possible use of residency education to ensure the output of highly trained and highly functional
practitioners who are able to best meet the needs of Canadians.
Re-entry
The situation of physicians already in practice who seek to pursue further training in another discipline. A
trainee carries the “re-entry” label for his or her entire training year regardless of the year in which

training was actually re-entered. For example, trainees designated as “re-entry” in 2003 could have re-
entered training in 2003 or a previous training year.
Generalist curriculum (Canada)

Training that is broad-based and encompasses a logical progression from breadth to focused
competencies required for Canadian specialist practice.
Generalist curriculum (USA)

In the United States, a “generalist curriculum” refers to training that promotes American primary care
disciplines (Family medicine, General Internal medicine and Pediatrics).
Generalism
Relating to an enhanced skills set that builds on the foundational specialty or a defined set of
competencies that is fundamentally required at the outset of further specialization. Factors that affect
generalism include educational program requirements and practice environment (service delivery
patterns and resource allocation). Potential skill sets are shaped by these two factors (as discussed by the
Conjoint Meeting of the RCPSC and the Standing Committee on PGME November 17 2006).

APPENDIX 2 – NATIONAL PHYSICIAN SURVEY 2007 DATA ANALYSIS
Premature career decision-making140
Table 1: Debt upon entering medical school
% of responses
1st year or année 2nd year 3rd or 4th year All students
Level of debt préparatoire (n = 897) (n = 781) (n = 1109) (n = 2819)
No debt 64.7 62.7 64 64.1
Less than $1000 2.3 3.1 2.5 2.6
$1001 to $5000 7.0 5.5 5.1 5.8
$5001 to $10 000 4.9 5.2 6.9 5.7
$10 001 to $20 000 7.0 6.3 7.1 6.8
$20 001 to $40 000 4.7 6.9 5.5 5.6
$40 001 to $60 000 1.3 2.2 2.3 1.9
$60 001 to $80 000 0.2 0.6 0.4 0.4
$80 001 to $100 000 0.1 0.1 0.3 0.2
$100 001 to $120 000 0.3 0 0.2 0.2
$120 001 to $140 000 0 0.1 0.2 0.1
$140 001 to $160 000 0 0 0.1 0
Over $160 000 0.2 0.3 0.2 0.2
I prefer not to provide this
information 1.4 1.3 0.5 1.0
No response 5.7 5.6 4.7 5.3
Total 100 100 100 100
Table 2: Debt upon entering medical school/residency training

% of responses
Family Medicine Other specialty medicine All residents
Level of debt (n = 282) (n = 451) (n = 733)
No debt 24.1 21.7 22.6
Less than $1000 0.4 0.2 0.3
$1001 to $5000 2.1 2.2 2.2
$5001 to $10 000 3.2 4.0 3.7
$10 001 to $20 000 4.6 8.0 6.7
$20 001 to $40 000 10.6 10.0 10.2
$40 001 to $60 000 9.6 8.2 8.7
$60 001 to $80 000 7.8 9.3 8.7
$80 001 to $100 000 6.4 8.4 7.6
$100 001 to $120 000 8.9 5.8 7.0

$120 001 to $140 000 2.8 3.3 3.1

$140 001 to $160 000 3.9 5.1 4.6
Over $160 000 3.5 1.6 2.3
information 0.7 2.7 1.9
Total 100 100 100
Table 3: Anticipated debt upon completion of medical training (undergraduate medical education)
% of responses
Level of debt préparatoire (n = 897) (n = 781) (n = 1109) (n = 2819)
No debt 11.9 9.3 10.0 10.4

Less than $1000 0.1 0.6 0.4 0.4
$1001 to $5000 3.0 2.3 2.3 2.5
$5001 to $10 000 5.4 4.4 3.2 4.3
$10 001 to $20 000 8.9 6.1 6.0 7.2
$20 001 to $40 000 11.3 11.8 12.4 12.0
$40 001 to $60 000 10.4 10.8 11.7 11.0
$60 001 to $80 000 7.9 9.7 10.4 9.4
$80 001 to $100 000 8.6 10.9 12.4 10.6
$100 001 to $120 000 10.5 11.1 8.7 9.9
$120 001 to $140 000 4.6 5.5 5.7 5.2
$140 001 to $160 000 5.9 5.5 6.1 5.9
Over $160 000 2.7 4.6 5.5 4.3
information 3.1 1.8 0.7 1.8
No response 5.8 5.5 4.5 5.2
Total 100 100 100 100

Table 4: Anticipated debt upon completion of medical training (residents)

% of responses
Anticipated l evel of debt (n = 282) (n = 451) (n = 733)
No debt 20.6 22.8 22.0
Less than $1000 0 0.4 0.3
$1001 to $5000 1.8 0.7 1.1
$5001 to $10 000 2.1 4.7 3.7
$10 001 to $20 000 5.7 6.2 6.0
$20 001 to $40 000 9.2 8.4 8.7
$40 001 to $60 000 11.0 8.0 9.1
$60 001 to $80 000 7.8 6.7 7.1
$80 001 to $100 000 6.4 8.0 7.4
$100 001 to $120 000 7.4 3.3 4.9
$120 001 to $140 000 2.8 3.3 3.1
$140 001 to $160 000 4.6 4.0 4.2
Over $160 000 7.4 10.4 9.3
I prefer not to provide this information 1.4 3.5 2.7
Total 100 100 100
Table 5: Anticipated level of debt upon completion of medical training

% of responses
Anticipated level of debt Medical students All residents
No debt 10 22
$0 to $60 000 37 29
$60 000 + 45 36
Table 6: Influence of debt on choice of specialty and career decisions (medical students)
% of responses
1st year or année 2nd year 3rd or 4th year All medical students
Plan of action to pay off debt préparatoire (n = 897) (n = 781) (n = 1109) (n = 2819)
Select a short residency program 13.1 17.8 16.2 15.6
Select a specialty I believe will
have high earning potential 20.1 23.2 24.1 22.6
Fulfill a service obligation 10.8 11.2 12.0 11.3
Practise in the United States 3.9 4.3 3.4 3.9
Pratice as a locum tenens 16.9 19.8 25.7 21.3
Practise where I am offered a
financial recruitment incentive 29.6 35.6 35.2 33.5

Practise where I am offered a non-

financial recruitment incentive 6.8 10.1 7.4 8.0
I do not intend to do any of the
above to pay off my debts 56.2 47.0 46.5 49.8
No response 1.8 2 1.5 1.8
Table 7: Influence of debt on choice of specialty and career decisions (residents)
% of responses
Family Medicine Other specialty All residents
(n = 282) medicine (n = 451) (n = 733)
I purposely chose a short
residency program 20.0 0.3 7.7
Did your debt when you I purposely chose a specialty
entered your residency that I believe to have a high
influence your choice of earning potential 2.8 14.7 10.2
specialty?
No influence 76.1 83.9 81.0
Fulfill a return of service
obligation 21.4 13.1 16.4
Practise as a locum tenens 58.8 28.7 40.5
financial recruitment
To pay off your debts, incentives 45.5 37.4 40.5
when you finish your
residency, do you intend to
non-financial recruitment
do any of the following?
incentives 8.0 6.9 7.4
Practise in the United States 1.6 6.2 4.4
None of the above will be
done to pay off debts 18.2 43.9 33.8
No response 1.1 1 1.1
Table 8: Exposure to different topics in medical school

Topic covered by majority of medical Topic not covered by majority of medical
% %
students in medical school students in medical school
Ethics and professionalism 86 Hands-on teaching 71
Communication skills 81 Emergency surgery 70
Evidence-based medicine 72 Intensive care unit care 69
Collaborative / interdisciplinary care 67 Office procedures 62
End of life issues 67 Coronary care unit 61
Critical appraisal skills 60 Hands-on research 60
Family Medicine rotations 55 Aboriginal care 58
Work in a health care system 55 Minor surgery 56
Internal medicine 54

Table 9: Level of familiarity with the work of health care professionals in different disciplines
% of responses
1st year or année
rd
préparatoire 2nd year 3 or 4th year All students
(n = 897) (n = 781) (n = 1109) (n = 2819)
Not at all familiar 1.7 0.9 0.6 1.0
Somewhat familiar 48.0 41.5 23.5 36.4
Family Physicians Very familiar 45.9 54.0 72.8 58.9
NR 4.3 3.6 3.1 3.7
Total 100 100 100 100
Psychiatric specialists Very familiar 8.0 17.8 47.5 26.6
NR 4.2 3.6 3.2 3.7
Total 100 100 100 100
Pediatric specialists Very familiar 10.4 15.9 48.2 27.2
NR 4.1 3.7 3.2 3.7
Total 100 100 100 100
Obstetrical /
Very familiar 9.8 21.9 57.9 32.5
gynecological specialists
NR 4.1 3.7 3.2 3.7
Total 100 100 100 100
Internal medicine
Very familiar 9.0 19.6 57.1 31.5
specialists
NR 4.0 3.7 3.3 3.7
Total 100 100 100 100
Surgical specialists Very familiar 11.5 20.2 53.7 30.9
NR 4.3 3.6 3.4 3.8
Total 100 100 100 100

Table 10: Level of satisfaction with exposure to different medical specialties in medical school
% of responses
st nd rd th
1 year / année préparatoire 2 year 3 or 4 year All students
Level of satisfaction (n = 897) (n = 781) (n = 1109) (n = 2819)
Very dissatisfied 2.3 1.7 0.7 1.5
Dissatisfied 12.9 12.9 5.5 9.9
Neutral 38.9 29.4 17.1 27.4
Satisfied 36.8 47.4 60.1 49.4
Very satisfied 4.9 4.9 13.3 8.1
No response 4.1 3.7 3.2 3.7
Total 100 100 100 100
Table 11: Selection of specialty area

% of responses
Factor that led to specialty selection (n = 282) (n = 451) (n = 733)
Intellectual stimulation / challenge 64.9 87.8 79.0
Doctor-patient relationship 84.8 53.7 65.6
Workload flexibility and/or predictability 79.1 50.3 61.4
Influence of a mentor 25.9 43.9 37.0
Influence of my family 16.7 8.4 11.6
Prestige 2.8 10.9 7.8
Earning potential 7.8 27.9 20.2
Research opportunities 2.1 28.2 18.1
Teaching opportunities 22.7 36.6 31.2
Ability to pursue non-work related interests 54.6 27.7 38.1
Availability of training opportunities 27.3 18.0 21.6
Other 13.8 6.0 9.0
No response 0 0 0
Column totals may exceed 100% as this question allowed for multiple responses.
Table 12: Marital status of medical students by year of study

% of responses
1st year / année 2nd year 3rd or 4th year All students
Status préparatoire (n = 897) (n = 781) (n = 1109) (n = 2819)
Married / living with partner 14.4 19.3 30.2 22.1
Single 85.4 80.2 69.3 77.5
Separated 0 0.3 0.4 0.2
Divorced 0 0 0.2 0.1
No response 0.2 0.3 0 0.1
Total 100 100 100 100

Table 13: Marital status of residents
% of responses
Status (n = 282) (n = 451) (n = 733)
Married / living with partner 63.8 55.7 58.8
Single 35.1 43.5 40.2
Separated 0.4 0.2 0.3
Divorced 0.7 0.2 0.4
No response 0 0.4 0.3
Total 100 100 100
Table 14: Parental status of medical students, by year of study

% of responses
1st year / année 2nd year 3rd or 4th year All students
Status préparatoire (n = 897) (n = 781) (n = 1109) (n = 2819)
Have children 2.5 4.4 6.5 4.5
Do not have children 97.3 95.6 93.2 95.3
No response 0.2 0 0.3 0.2
Total 100 100 100 100
Table 15: Parental status of residents, by area of study
% of responses
Status n = 282 n = 451 n = 733
Have children 29.4 19.7 23.5
Do not have children 70.6 80.3 76.5
Total 100 100 100
Table 16: Expecting a child (medical student)

% of responses
Expecting a child préparatoire (n = 897) (n = 781) (n = 1109) (n = 2819)
Yes 0.4 1.4 1.4 1.1
No 97.3 97.2 97.4 97.3
No response 2.2 1.4 1.3 1.6
Total 100 100 100 100

Table 17: Expecting a child (residents)

% of responses
Expecting a child n = 282 n = 451 n = 733
Yes 8.9 6.4 7.4
No 89.7 91.6 90.9
No response 1.4 2 1.8
Total 100 100 100
Table 18: Marital status and intent to practise in same field of training (Family Medicine residents)
Intent to % of responses
practise as a
family physician Married / living
(general with partner Single Separated Divorced Total
practitioner) n = 180 n = 99 n=1 n=1 n = 282
Yes 79.4 80.8 100 100 100
No * * * * *
Don’t know yet * * * * *
No response * * * * *
Total 100 100 100 100 100
* The 2007 National Physician Survey suppresses responses when column n is less than 30.
Table 19: Marital status and intent to practise in same field of training (other specialty medicine)
% of responses
Intent to practise as a family Married / living with
physician (general partner Single Separated Divorced Total
practitioner) n = 251 n = 196 n=1 n=1 n = 451
Yes 84.9 84.2 100 100 100
No * * * * *
Don't know yet * * * * *
No response * * * * *
Total 100 100 100 100 100
*The 2007 National Physician Survey suppresses responses when column n is less than 30. No responses = 2

Table 20: Level of preparation medical school provided for residency training
% of responses
Medical training has prepared
you (or will prepare you) for 1st year or année 2nd year 3rd or 4th year All students
residency training préparatoire (n = 897) (n = 781) (n = 1109) (n=2819)
Strongly agree 10.4 6.7 14.0 10.7
Agree 37.6 42.6 46.9 42.9
Neutral 38.7 30.9 21.1 29.3
Disagree 7.2 14.1 12.4 11.2
Strongly disagree 2.2 2.0 2.6 2.3
No response 3.9 3.7 3.1 3.5
Total 100 100 100 100
Table 21: Intention to practise in the field of current training:

other specialty medicine residents (n = 451)
Intends to practise in current field of training % of responses

Yes 84.7
No 4.9
Don't know yet 5.5
No response 4.9
Total 100
Table 22: Intention to practice as a family physician (general practitioner):

Family Medicine residents (n = 282)
Intends to practise as FP/GP % of responses
Yes 80.1
No 6.0
Don't know yet 6.4
No response 7.4
Total 100

Quality PGME
Table 23: Level of satisfaction with residency training program

% of responses
Family Medicine Other specialty

Level of satisfaction (n = 282) medicine (n = 451) All residents (n = 733)
Very dissatisfied 0.7 0.7 0.7
Dissatisfied 2.1 3.8 3.1
Neutral 9.6 10.4 10.1
Satisfied 54.3 46.8 49.7
Very satisfied 27.3 35.0 32.1
Total 100 100 100
Table 24: Level of preparation provided by residency training for future practice:
other specialty medicine residents (n = 451)
% of responses
Yes 79.8
Residency training will prepare No 3.3

you for the kind of practice Don’t know yet 13.7
you are planning to undertake
No response 3.1
Total 100
Table 25: Areas of training considered to be lacking by specialist residents

Area of training % of responses
Procedural skills 24.7
Exposure to clinics and health care outside of hospitals 14.3
Office/business management 9.1
Other 51.9
Total 100

Table 26: Level of balance that residency training program provided (academic versus clinical skills)
Academic and clinical % of responses
service components of
residency training program Family Medicine Other specialty medicine All residents
are balanced (n = 282) (n = 451) (n = 733)
Strongly agree 12.4 17.5 15.6
Agree 48.6 51.4 50.3
Neutral 18.4 15.3 16.5
Disagree 13.1 10 11.2
Strongly disagree 1.8 2.7 2.3
Total 100 100 100

APPENDIX 3 – SUMMARY DATA FROM THE CCP SURVEY141
KEY RESULTS OF THE CORE COMPETENCY PROJECT SURVEY, 2008 Data
Career decision-making
Medical students – 84%
All Residents – 79%
The majority of respondents within each respondent group agreed that most
All Physicians – 70%
medical students successfully match into their first choice of disciplines.
Program Directors – 89%
Medical Leaders – 88%
Lifestyle and work balance
Lifestyle and work balance is the most important factor in choosing a discipline Family medicine (FM) residents – 80%
for medical students, Family Medicine residents, Family Medicine physicians and FM physicians – 62%
program directors. Intellectual content of the discipline is the most important Program Directors – 66%
factor for specialty medicine residents and specialty physicians. Intellectual content
Royal College (RC) residents – 77%
RC physicians – 73%
Clinical exposure
Clinical exposure to other disciplines is the biggest challenge in choosing a career
discipline followed by the timing of career choice for all groups except the
medical leaders. Medical leaders view the timing of career choice as the biggest
challenge. Program Directors – 80%
Timing of career choice
FM Residents – 34%
RC Residents – 53%
The % of elective rotations that medical students do or should do in their first
FM Physicians – 32%
choice of career discipline, varied among all groups.
RC Physicians – 31%
RC Residents – 20%
More than half of medical leaders agree that medical students would benefit FM Physicians – 26%
from a reduced number of entry disciplines while medical students and residents RC Physicians – 26%
are least likely to agree. Program Directors – 44%

Flexibility
Three in 10 medical students have the impression that between 11% and 20% of Medical students – 30%
residents consider switching. Of the residents and physicians surveyed, All Residents – 37%
approximately one third considered switching during residency. The impression All Physicians – 32%
of the % of residents that switch is lower for program directors and medical Program Directors – 15%
leaders Medical Leaders – 17%
Physicians, program directors and medical leaders are fairly close in their All Physicians – 50%
perception of the % of residents who have spoken to a faculty member about Program Directors – 46%
switching. Of the residents surveyed, approximately 4 in 10 have spoken to a Medical Leaders – 42%
faculty member about switching. Residents – 39%
The majority of residents surveyed, stated they are satisfied with the credit they Residents – 72%
received when they switched. Significantly less programs directors and medical Program Directors – 26%
leaders had the impression that this was the case. Medical Leaders – 30%
Number of funded residency positions
The number of funded residency positions followed by the ability to transfer All Residents – 55%
credit for completed training, were cited as the largest barriers to switching All Physicians – 64%
disciplines for all respondent groups. Program Directors – 83%
PGME Structure
Physicians (RC & CFPC) are most likely to agree that all first-year residents should
do a broad-based common PPGY-1 like a rotating internship.
RC residents – 49%
FM residents – 61%
Family physicians are the most likely to agree that residents should match into a
RC physicians – 69%
limited number of core streams then branch out.
FM physicians – 75%
Program directors – 68%
Medical leaders – 58%
Among medical students, FM residents and all physicians, a common PGY-1 like a SC Residents – 22%
rotating internship best reflects their views on residency training. All Physicians – 55%


All groups surveyed except medical students, believe that the current PGME All Residents – 44%
system produces too few generalists. Medical students say that putting a
stronger or earlier emphasis on broad-based generalist training best reflects
their view. Program Directors – 37%
More than three in five medical leaders (more than any other group) say that the All Residents – 53%
Canadian medical education system is effective at meeting the needs of those it Physicians – 43%
serves. Physicians are most likely to disagree. Program directors – 53%
Medical leaders – 63%
Among medical students, program directors and medical leaders, creating more Medical students – 12%
residency positions is the most important improvement to Canada’s residency Program directors – 10%
education system. Other groups pointed to increased flexibility to change Medical leaders – 10%
programs and the implementation of a common PGY-1.

APPENDIX 4 – CARMS SURVEY COMPARISON142

The following frequency table reported the distribution of CaRMS survey respondents based on a categorical
comparison between those classified as either “Dissatisfied” or “Satisfied.” These two categories were defined
on the basis of responses to questions C6 and C7, listed below. Although we have collected data from the
2000 and 2002 CaRMS surveys, these questions have changed over the years and have not been assessed at
this time.
Questions used to determine satisfaction category:
C6. Do you plan to complete training in the discipline to which you were matched?
C7. If the opportunity were available, would you plan to change your residency discipline?
Category definitions:
Satisfied: Answered “Yes” to C6 and “No" to C7.

Dissatisfied: Answered “No” to C6 or “Yes” to C7.
Frequency results:
SATISFACTION WITH RESIDENCY MATCH
Dissatisfied Satisfied
Year N n (%) n (%)
2006 1445 78 (5.4) 1223 (84.6)
2005 1080 64 (5.9) 887 (82.1)
2004 970 44 (4.5) 796 (82.1)
2002 722 32 (4.4) 561 (77.7)
2000 821 63 (7.7) 624 (76.0)

APPENDIX 5 – ELECTIVES POLICIES OF CANADIAN MEDICAL SCHOOLS143
MEDICAL SCHOOL ELECTIVES POLICIES AND PROGRAM REQUIREMENTS
Medical school Program requirements

University of Alberta All students must do a minimum of 3 electives in different specialties of at least 2
weeks in duration over the two-year period. Students must complete a minimum of
13 weeks of clinical electives during their clinical portion of the program.
Year 3 – each student must complete a minimum of 5 weeks of clinical elective time.
Year 4 – each student must complete a minimum of 8 weeks of clinical elective time.
There are four categories of electives: basic science, research, clinical specialties and
medically related sciences.
University of British Columbia Policy is being changed for 2007. Currently, students are required to do no more than
12 weeks in one discipline (out of a total of 20 weeks of electives and selectives in
the fourth year).
Dalhousie University No restrictions on electives: 12 weeks minimum and in final year. Students can
choose all their electives in 1 discipline or more – selection can be as broad or narrow
as they desire. This is in addition to clerkship rotations in Internal Medicine, Family
Medicine, Psychiatry, Surgery, Emergency Medicine, Pediatrics and Obstetrics and
Gynecology. Clerks also complete a 9-week unit in Continuing and Preventive Care.
This unit is organized as three, 3-week rotations and is centred on ambulatory-based
patients and community involvement. Clerks will also complete a 3-week rotation in
Care of the Elderly.
The second half of the year (for the other 12 weeks) is an area of focused study:
students must complete four 3-week rotations in geriatrics, community-based
medicine and chronic disease management as well as an open rotation.
University of Manitoba Each elective should be a minimum of at least 2 weeks; students must complete
electives in at least three different disciplines/departments.
Memorial University No restrictions on electives: students must complete a minimum of 2 weeks or a

maximum of 8 weeks in any elective they choose; this is done closer to the end of
their third year or in their fourth year.
McGill University Electives must be carried out in a minimum of three different disciplines.
Opportunities for elective rotations are provided to complement students’ training as
they see fit. This may involve addressing an area of perceived or actual weakness,
complementing core rotations by exposure to disciplines that have been relatively
under-represented, or for the purpose of “testing out” a discipline that is of
particular interest as a potential career.
McMaster University Clinical electives must be organized so that students have an elective experience in a
minimum of three different disciplines (defined below) throughout their 24 weeks of
electives, each of which shall take place for a minimum of 2 weeks. Disciplines:
Anesthesiology, Community Medicine, Critical Care, Diagnostic Radiology, Family
Medicine, Emergency Medicine, Laboratory Medicine, Internal Medicine, Obstetrics
and Gynecology, Pediatrics, Psychiatry, and Surgery.
University of Ottawa No restrictions on length or variety of electives chosen.
Queen’s University Electives must be at least 14 weeks total and start in the second half of the third year.
Students must complete a minimum of 3 electives in different specialties of at least 2
weeks in duration (new policy). Clinical clerkship rotations begin in the third year and
consist of rotations in Acute Care, Family Medicine, Core Medicine, Specialty Medicine,

Obstetrics and Gynecology, Pediatrics, Psychiatry, and Core Surgery.
University of Toronto Each student must have an elective experience in a minimum of three different
disciplines, each of which shall take place for a minimum of two weeks.
Year 3 – Phase I Clerkship Electives: Students are required to complete a 6-week
elective block during Phase I Clerkship. To allow for flexibility, students may subdivide
the 6 weeks into shorter periods, with the requirement that no period will be less
than 2 weeks and that the various periods add up to 6 weeks in total. Consideration
will also be given to a longitudinal split between two experiences, such as by
spending mornings in one elective setting and afternoons in another.
Year 4 – Phase II Clerkship Electives: Students are required to complete two 6-week
elective blocks during the Phase II Clerkship. Both of these elective blocks may be
subdivided into 2 periods, with no period being less than 2 weeks. Consideration will
also be given to a longitudinal split between two experiences, such as by spending
mornings in one elective setting and afternoons in another.
University of Western Ontario Clerkship begins in September of the third year and consists of a 1-week orientation
followed by 51 weeks of an integrated clerkship. In the third year, rotations are done
in Internal Medicine, Medicine (selectives), Surgery, Family Medicine, Pediatrics,
Psychiatry, and Obstetrics and Gynecology. This is followed by the Clinical Science
Electives and Transition period in the fourth year, where eight 2-week electives may
be chosen in areas of interest to students. Students have wide latitude in their
electives but must choose different categories and ensure they select 4 weeks in a
different area. The groups are divided as follows:
Group 1: Medicine, Pediatrics, Neurology, Critical Care
Group 2: Anesthesiology, Surgery, Obstetrics and Gynecology
Group 3: Family Medicine, Psychiatry, Community Medicine, Dermatology, Allergy,
Rheumatology, Physical Medicine and Rehabilitation, Oncology, Emergency Medicine
Group 4: Radiology, Nuclear Medicine, Pathology, Clinical Pharmacology
Group 5: Research, overseas electives
To be approved, electives must be shown to be broadly based. This means choosing
electives from at least two different categories. Wide variety in choices is advised.
University of Saskatchewan The MD program is designed to ensure that participants graduate with a common
foundation of knowledge, skills, values and attitudes. This general professional
education prepares undifferentiated graduates for subsequent education in primary
or specialty care areas. The clinical clerkship occurs in year 3 and year 4. Students are
assigned to a series of core, selective and elective clinical rotations. Selectives are
chosen from a defined set of options. Electives can be done in any discipline. Clinical
clerks are known as Junior Undergraduate Rotating Student Interns. Core rotations
include Anesthesiology (2 weeks), Family Medicine (6 weeks), Emergency Medicine (2
weeks), Internal Medicine, including Geriatrics and Neurosciences (12 weeks),
Surgery (8 weeks), Obstetrics and Gynecology (6 weeks), Pediatrics (6 weeks) and
Psychiatry (6 weeks). There are 12 weeks of elective time, usually done in 4-week
blocks, and 4 weeks of selective time.
Northern Ontario School of No data available.

Medicine
University of Calgary Students have 2 weeks for electives at the end of the first year and 4 weeks of
elective time at the beginning of the second year. Another 10 weeks are available for
electives during the clerkship year. Along with this 10-week elective time, there are
seven mandatory clerkship rotations in Anesthesia (2 weeks), Family Medicine (4
weeks), Internal Medicine (12 weeks), Obstetrics and Gynecology (6 weeks),
Pediatrics (6 weeks), Psychiatry (6 weeks) and Surgery (8 weeks).
l’Université de Montréal No data available.

Université Laval Students are required during the first year to complete only a 1-week elective within
a hospital environment. Electives are available for a duration that varies between 3
and 8 weeks depending on the students’ objectives, but these not mandatory.
Université de Sherbrooke Students are required to complete 3 “stages d’options.” There are 3 courses in total,
each lasting 4 weeks for a total of 12 weeks.

APPENDIX 6 – CARMS RESIDENCY MATCH 2002–2008144
RESIDENCY MATCH 2002–2008

Total graduates (available positions)
School 2002 2003 2004 2005 2006 2007 2008

Memorial 42 (57) 56 (60) 55 (60) 57 (62) 51 (63) 57 (66) 59 (64)
Dalhousie 76 (96) 80 (96) 83 (99) 87 (97) 80 (99) 100 (107) 93 (110)
Laval/Montréal/ 13 (nd) 15 nd 15 nd 22 nd 467 (502) 508 (574) 541 (615)
Sherbrooke
McGill 67 (91) 91 (105) 96 (114) 99 (125) 127 (137) 132 (150) 164 (167)
Ottawa 84 (95) 87 (101) 90 (104) 114 (124) 134 (129) 132 (158) 134 (170
Queen’s 69 (62) 79 (69) 80 (69) 88 (76) 101 (83) 95 (98) 98 (103)
Toronto 162 (211) 177 (218) 181 (223) 188 (238) 190 (259) 200 (342) 187 (363)
McMaster 100 (100) 111 (105) 123 (120) 137 (123) 143 (126) 136 (144) 150 (167)
Northern Ontario – – – – – – – – – – – – – (34)
Western Ontario 90 (92) 99 (97) 99 (92) 122 (103) 131 (112) 130 (138) 134 (145)
Manitoba 68 (77) 73 (77) 73 (78) 79 (85) 88 (93) 87 (94) 88 (93)
Saskatchewan 55 (57) 55 (57) 53 (57) 56 (59) 58 (60) 65 (65) 61 (79)
Alberta 100 (115) 103 (115) 123 (126) 128 (132) 125 (132) 133 (135) 127 (134)
Calgary 71 (81) 88 (93) 97 (104) 96 (105) 111 (108) 101 (104) 103 (109)
University of British 120 (126) 117 (124) 117 (158) 132 (179) 130 (198) 124 (242) 195 (245)
Columbia
Total 117 (1260) 1231 (1317) 1285 1404 1405 1508 1936 2101 2000 2417 2134 2598

APPENDIX 7 – RE-ENTRY POLICIES OF CANADIAN MEDICAL SCHOOLS145
RE-ENTRY POLICIES OF CANADIAN MEDICAL SCHOOLS

Province/school Policy Key points
ALBERTA  For rural physicians  No dedicated re-entry
 Opportunity to return for training in a Royal College positions. Number of
University of Alberta specialty program re-entry positions
depends largely on the
 Number of positions varies from year to year
University of Calgary applicant pool
 One was available for 2004, one for 2005, none for
 1st iteration: no ROS
2006; the number for 2007 will be known only after
requirement
the CaRMS match
 2nd, 3rd and 4th iteration:
 1st iteration: open to physicians who are on the Alberta
ROS in rural
Medical Register and currently practise in rural
community in Alberta
Alberta. No requirement for Return-of Service (ROS)
 1997–2007: 20 re-entry
 2nd iteration: if positions remain vacant, they will be
trainees
available to physicians who are on the Alberta Medical
Register and are practising in Alberta. These
physicians must have signed a Return-in-Service
agreement with a Regional Health Authority (RHA)
for a rural community in Alberta
 3rd iteration: open to all physicians who are eligible for
the Alberta Medical Register. These physicians must
have a signed an ROS agreement with an RHA for a
rural community in Alberta
 4th iteration: all other physicians who are eligible for
the Educational Register. These physicians must have
a signed a ROS agreement with an RHA for a rural
community in Alberta
 If there are more candidates than positions available in
the 1st iteration, applications will be ranked according
to stated criteria: licence status, length of practice in
Alberta, clinical practice and location of practice
 University of Calgary re-entry training eligibility: All
physicians already in practice in Alberta (in an urban
or rural area) who wish to re-enter a residency training
program
BRITISH  UBC does not have an ongoing re-entry program  No dedicated re-entry
COLUMBIA whereby a certain number of positions per year are set positions. Ad hoc
aside specifically for re-entry candidates. Some allocations, based on
University of British Internal Medicine and General Surgery positions were availability of positions
Columbia (UBC) offered on an ongoing basis in 2001–2004. However, after CaRMS match
this has been discontinued and rolled into CaRMS. All and requests
re-entry positions are allocated ad hoc according to the  1996–2006: 55
availability of positions after the annual CaRMS re-entry trainees
match. The postgraduate deans poll all programs to
see if they wish to have re-entry positions and allocate
positions on the basis of these requests. Criteria:
 must be a citizen/landed immigrant, fully licensed in
the province where the candidate resides, not currently

enrolled in a residency training program

MANITOBA  3 positions have been offered outside of the CaRMS  ROS requirement
match over a 6-year period. These are all tied to ROS.  Priority given to FMs
Priority is given to Family/General Practice physicians who wish to re-train in
University of
who wish to obtain a primary specialty recognized by an RC specialty
Manitoba
the RCPSC
 2000–2006: 3 positions
 Eligibility critera: offered outside of the
o Must be fully licensed to practise medicine in the match
Province of Manitoba
o Must have been in practice in Manitoba for at
least 1 year
o Must be willing to be interviewed by a PGME re-
entry committee
o Must provide a letter of good standing from the
College of Physicians and Surgeons of Manitoba
o Must enter an ROS agreement to practise in
Manitoba on a year-for-year basis after
completion of residency training
NEWFOUNDLAND  Positions are offered in areas of recognized need in the  Re-entry based partly
AND LABRADOR province on the number of
 All positions are attached to mandatory ROS to the unfilled positions after
Memorial University province (1 year for 1 year of training; credit will be CaRMS match second
of Newfoundland granted for prior service in the province) iteration
 Priority is given to physicians who have worked in the  Assigned quota = 1 and
province, but applications from outside the province increases depending on
will be considered unfilled CaRMS
positions. ROS
 Applicant qualifications must be at least equivalent to
requirements
that expected for regular ministry-funded residency
positions and meet the criteria of the College of  1996–2006: 52
Physicians and Surgeons of Newfoundland and re-entry trainees
Labrador for eligibility on the Educational Register
 Positions are not offered until the pool of applications
comes in. There is no predetermined number of
positions offered per year or per specialty; the quota is
decided after a review of the applications and
depending on the applicant pool. The quota for
Special Funded positions at Memorial has been partly
based on the number of unfilled positions after the
CaRMS match second iteration. There is generally an
assigned quota of one (1), with the understanding that
the quota will increase based on unfilled positions
from 2nd Iteration. Individuals are encouraged to
apply to both routes of entry. All positions are put in a
general PGME Pool. The assignment of positions to
programs is based on “program resources available”
(dependent on, but not limited too, internal factors
such as residents leaving programs prematurely as a
result of internal or external transfers, “provincial
need” and merit of application
NOVA SCOTIA  Priority is given to specialty training areas with a  ROS requirements.
Dalhousie perceived projected resource need as determined by Letter sent to DM

the Department of Health and the Medical School Nova Scotia

 Preferred specialties identified by the Department of  1998–2007: 14 re-entry
Health are: General Surgery, Neurology, ObGyn, trainees
Orthopedic Surgery, Otolaryngology and Psychiatry
 Re-entry is available only to physicians who are
Canadians/landed immigrants who have practised in
Nova for a minimum of 2 years
 Candidate must hold an unrestricted license for
independent practice
 Candidate must have a satisfactory “certificate of
professional conduct” from the College of Physicians
and Surgeons of Nova Scotia
ONTARIO  Physicians accepted for a re-entry training position  Dedicated positions, all
must commit to providing full-time service in an with ROS
McMaster University under-serviced community, acceptable to the Ministry requirements.
of Health and Long-Term care, upon completion of  1997–1999: 25
Queen’s University
training. For one to two years of training, the Return of positions
University of Ottawa Service commitment will be one year. For three to five
 2000–2006: 40
University of Toronto years of training, the Return of Service commitment
will be two years  2007: 50
University of Western
Ontario  Family medicine: third-year program in Emergency  1997–2006: 158
Medicine, Anesthesia or Care of the Elderly. The re-entry trainees
Ministry will also consider applications in mental
health, women’s health, palliative care, surgical skills
and obstetrical skills, if the physicians can document
satisfactorily the need for these skills in a specific
rural/northern community; or,
 A specialty program in anatomical or general
pathology, general surgery, obstetrics/gynecology,
general internal medicine, psychiatry, anesthesia,
orthopedic surgery, diagnostic radiology, radiation
oncology and community medicine. Other specialties
may be considered if the applicant can provide
evidence of a defined need in a specified community
 Specialists: up to 2 years of Family Medicine training
leading to certification by the CFPC, or:
 A preferred specialty in anatomical pathology or
general pathology, general surgery,
obstetrics/gynecology, general internal medicine,
psychiatry, anesthesia, orthopedic surgery, diagnostic
radiology, radiation oncology and community
medicine
 ROS requirements for certain positions may differ
 Candidate must hold a current unrestricted certificate
of registration for independent practice from a
provincial college of physicians and surgeons
 Must have practised in home province for a minimum
of 6 consecutive months at the time of application
QUEBEC  Physicians practising in Quebec or graduates from a
Quebec medical school may be considered for “retour
de pratique” positions in Family Medicine or a
McGill University
specialty, via the "special quota" created by the

Laval Quebec Government

Université de  Eligibility criteria:
Montréal o Must hold citizenship/residency
Université de o Must have practised in Quebec at least 6 months
Sherbrooke over the course of a 5-year period. For Quebec
MDs, this practice experience can be outside of
the province
 The Collège des médecins du Québec (CMQ) has
verified the equivalence of all medical degrees issued
by a Canadian school outside Quebec and by all US
schools. The CMQ will issue a training card, which is
required to be able to train in Quebec hospitals and be
paid by the provincial ministry of health
SASKATCHEWAN  Funding is provided for 2 currently practising  Dedicated positions.

Saskatchewan family physicians to re-enter a specialty Positions are not
University of training of their choice. The re-entry training program assigned to specific
Saskatchewan consists of the provision of a training grant of specialties but on the
approximately $50,000 available to rural basis of program
Saskatchewan family physicians. capacity in any given
 Eligibility criteria: year
o Must have or be eligible for licensure as a family  4 positions available per
physician in the province year. 2 funded by SMA
and restricted to rural
o Minimum of 3 years of practice prior to
family physicians and 2
application.
provided by SaskHealth
o Must provide 1 year of service in Saskatchewan with no restrictions
for every year that funding was received. If a
 14 positions in total,
candidate does not provide their ROS
offered since 2000 with
commitment in a Saskatchewan community, they
10 awarded (funded by
will be required to repay their bursary and
SMA)
administrative costs plus accumulated interest
 10 funded by
 Selection criteria: The number of years spent in
SaskHealth from 2002,
practice in Saskatchewan; willingness to work in
with 11 awarded
Saskatchewan upon completion of program, entering a
(because of extra
specialty identified as being one of need in the
funding)
province. Preference is given to those who intend to
practise in an underserviced area in Saskatchewan

APPENDIX 8 – NUMBER OF RE-ENTRY TRAINEES, 2001–2008146

APPENDIX 9 – SWITCHING BETWEEN TRAINING FIELDS, 2000–2007147
NUMBER OF TRAINEES WHO HAVE SWITCHED BETWEEN MAJOR TRAINING

FIELD CATEGORIES
Changes between Family Medicine (FM) and specialty training fields
Year Changes from FM to any specialty Changes from any specialty to FM
2000–2001 38 48
2001–2002 36 45
2002–2003 31 49
2003–2004 36 46
2004–2005 33 38
2005–2006 35 39
2006–2007 37 34
Changes between specialty fields
Changes from medical specialties to surgical Changes from surgical specialties to medical
specialties specialties
2000–2001 12 24
2001–2002 6 36
2002–2003 13 26
2003–2004 9 30
2004–2005 10 33
2005–2006 17 34
2006–2007 14 25
Total changes among training field groups
2000–2001 122
2001–2002 123
2002–2003 119
2003–2004 121
2004–2005 114
2005–2006 125
2006–2007 110
Most program changes occur at the R-1level. Table includes program changes at all levels.

APPENDIX 10 – CHANGES AMONG TRAINING FIELD GROUPS, 2000–2007148

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questionnaire. Available from: www.nationalphysiciansurvey.ca (accessed 2008; Aug 1).
141
Harris/Decima. Core Competency Project Research Report. Delivered to the Royal College on January 14, 2009.
142
CaRMS survey data received by the Royal College August 2006 and analyzed by the Educational Research and Development
Unit.
143
Web-based research and communication (phone and e-mail) between Royal College staff and medical schools, March 2007.
144
The Canadian Residency Match Service (CaRMS). Summary of match results. CaRMS First Iteration R-1 Match Reports 2002-
2008. Accessed January 30, 2009. http://www.carms.ca/eng/ndex.shtml
145
This research was conducted by phone, e-mail and web searches, March 2007.
146
CAPER data provided to the Office of Education, RCPSC, March 12, April 5, 2007 and December 9, 2008.
147
CAPER. Changes among Training Field Groups in Canada 2000-2006. CAPER Annual Census, Supplementary Data Tables.
148
CAPER. Changes among Training Field Groups in Canada 2000-2006. CAPER Annual Census, Supplementary Data Table J6.

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February

A FINAL REPORT of the CORE

The Royal College of Physicians and Surgeons of Canada

Copyright © 2009 The Royal College of Physicians and Surgeons of Canada.

Printed in Ottawa, Ontario, Canada

How to reference this document:

© 2009 THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA

Recurring issues in Canadian postgraduate medical education 3

History of the movement toward the Core Competency Project 5

Societal health needs 7

SECTION 2: PROJECT HISTORY TIMELINE 10

SECTION 3: PROJECT ACTIVITY TIMELINE 12

SECTION 4: PROJECT METHODOLOGY 14

SECTION 5: KEY FINDINGS 19

Premature career decision-making 19

Barriers to switching career paths 26

Quality postgraduate medical education 29

SECTION 6: DISCUSSION AND ANALYSIS 35

The timing of career choice and satisfaction with choice 35

Switching and re-entry 37

SECTION 7: DIRECTIONS FOR THE COLLEGES 44

2: National Physician Survey 2007 data analysis 48

3: Summary data from the CCP survey 59

4: CaRMS survey comparison 62

5: Electives policies of Canadian medical schools 63

6: CaRMS residency match, 2002–2008 66

© 2009 THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA

7. Re-entry policies of Canadian medical schools 67

8. Number of re-entry trainees, 1991–2008 71

9. Switching between training fields, 2000–2007 72

10. Changes among training field groups, 2000–2007 73

LIST OF TABLES and FIGURES

Figure 1: Historical recognition of medical specialties and subspecialites in Canada, 1919-2009 4

Table 1: Literature review methodology summary 15

Table 2: Commentaries and Focus Groups methodology summary 17

Table 3: Preparedness for residency training 21

Table 4: Medical students’ satisfaction with level of exposure to specialties 23

Table 5: Reported barriers to switching disciplines in residency 38

Figure 5: Percentage of medical residents who have considered switching disciplines 39

Table 6: Views of the current postgraduate medical education system 41

Table 7: Level of satisfaction with residency training program 41

© 2009 THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA

© 2009 THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA

 the quality of postgraduate medical education

© 2009 THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA

According to an influential 1996 RCPSC Report,

the primary objective of specialist postgraduate medical education is to prepare an

© 2009 THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA

© 2009 THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA

History of the movement toward the Core Competency Project

Developments within the Royal College

© 2009 THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA

Developments within PGME

© 2009 THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA

Societal Health Needs

 Adoption of the CanMEDS Physician Competency Framework in 1996.

© 2009 THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA

 Family Medicine is a community-based discipline. As a member of the community, the family

“The Population Perspective”

© 2009 THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA

© 2009 THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA

Section 2: Project History Timeline

1986 Canadian Medical Described the feasibility and merits of