The HHR Platform is a first-of-its-kind comprehensive career planning resource for medical students in Canada. It is a national, interactive, web-based tool that uses a map, comparison table, and trends graph to illustrate the most relevant public data on current and projected physician workforces across Canada. The goal is to facilitate medical student specialty choice to be based on both personal interest and population healthcare needs. Over time, these decisions comprise a component of national PRP strategy to help correct the physician supply-demand mismatch across Canada.
In Canada, current national PRP strategies aimed at the medical training process focus on two checkpoints: admissions into medical school and admissions into a residency program—representing top-down approaches. Both checkpoints will be discussed regarding most recent PRP initiatives which have paved the course for the HHR Platform as a contemporary, bottom-up PRP strategy targeting undergraduate medical trainees in Canada.
PRP via admissions into medical school
In Canada, medical school admissions represent the number of physicians who will be eligible to practice medicine within the next decade—barring minor exceptions such as visa trainees, immigration or emigration of graduated students, and attrition from medical training. Increasing the total number of medical school positions results in a greater supply of physicians. The decision to add or remove these positions is a result of complex processes between the provincial Ministry of Health and their health authorities, the faculties of medicine, and the respective provincial and territorial medical association [28].
Historically, the medical school admissions process has affected the physician workforce composition in two ways. First, individuals originally from a rural region are more likely to stay and practice medicine in a rural region [29–31]. Following this concept, the Northern Ontario School of Medicine (NOSM) was established to train students from Northern Ontario to respond to the region’s need for physicians in rural, Francophone, and Indigenous communities [32]. The school was established in 2005, and consistently above 90% of each incoming class are individuals from Northern Ontario [33]. In 2020, the rate of medical students pursuing residency programs at NOSM and then practicing in Northern Ontario averaged 40% and 94%, respectively, with similar rates for the past ten years. Several other institutions have similar admissions pathways for individuals from underserved or rural communities [34].
Secondly, individuals who share similarities with a particular demographic tend to practice and stay in these communities [29]. Therefore, quotas reserved for applicants meeting certain characteristics, such as indigenous and/or lower socioeconomic status, have been applied in some Canadian medical faculties. Additionally, the admission selection process now includes coefficients accounting for diversity and/or criteria for Black and refugee applicants in some schools [35]. In 2017, seven schools had a set number of seats allocated for indigenous students, and now all 17 Canadian medical faculties ensure a minimum number of indigenous students are admitted [36]. At least six institutions have constructed admissions pathways to recruit historically underrepresented and/or culturally diverse individuals, with many more institutions formally dedicated to developing similar streams [37]. Improving access to high-school and undergraduate mentorship is also an essential component to many of these initiatives. There is presently a paucity of data for the admissions outcomes of such initiatives due to their recency [38]. However, the University of Toronto’s Black Student Admission Program, which was launched in 2017, has shown promising early outcomes. In 2020, there were 20 Black medical students among a cohort of 259 learners—compared to one Black medical student in 2016—despite Black Canadians comprising 10% of Toronto’s population [39]. The overarching goal of such initiatives is to restructure the composition of our physician workforce to better reflect and serve the Canadian population.
The checkpoint of admissions into medical school has an influence on PRP in regards to determining the anticipated number of physicians, as well as their distribution by utilising quotas and geographical location of training sites. There are currently no mechanisms in place at this level that have been shown to impact specialty choice. Canadian medical students, therefore, begin medical school with the possibility of pursuing a residency in any discipline offered as part of the CaRMS.
PRP via admissions to residency
The CaRMS is a service that aims to match medical students to Canadian residency training positions through a Nobel prize winning algorithm [40]. The service centralizes all available Canadian residency training positions into one portal. A small minority of programs have also instituted return-of-service agreements upon completion of training in exchange for a residency position [41]. Once a student is matched to a residency program via the CaRMS, they are legally bound to that program. This helps to ensure an equitable and accountable system for residency program matching. Overall, the CaRMS represents residency admissions and affirms the importance of PRP as it pertains to the quota of residency positions and mix of specialties required by the Canadian population.
While PRP via residency and medical school admissions have helped to improve physician-based HHR in Canada, there remain critical gaps in this approach. The CaRMS match outcomes are a testament to the shortcomings of the current top-down PRP strategy. The most recent example is the significant rise in the number of unmatched Canadian medical graduates (CMG), reaching a peak of 169 in 2018 after both iterations of the match [16,42]. Estimates place the tax-base investment at approximately $260,000 per medical graduate prior to entering residency, representing at least $43.9M of unrealized investment in 2018 alone [17]. This has led to important advocacy efforts in 2018 and action in the following year whereby the Nova Scotia Health Ministry added 25 new spots at Dalhousie University as well as $23 million invested over six years for new positions in Ontario [42,43]. Concurrently, the number of unmatched CMGs has dropped to 98 in 2019 and 67 in 2020 [44]. Whether this is a direct result of the addition of these new positions has not been studied. Nonetheless, each unmatched CMG represents ineffective use of health human resources and subsequent loss of return-on-investment of Canadian taxpayers.
While the unmatched CMG phenomenon is multifactorial, a factual observation is that certain specialties are more competitive than others, as represented by the ratio of positions divided by applicants’ first choice discipline, thus correlating with medical student interests. In the 2020 residency match, the most competitive specialty was ophthalmology with a ratio of 0.51, and the least competitive specialty was general pathology with a ratio of 4.5 [44]. Family medicine was the sixth least competitive specialty with a ratio of 1.65. Even now, two years after the unmatched CMG peak, the interests of medical students have remained largely similar to what they were five years ago [15]. Importantly, these competitive specialties are not necessarily those that correlate to the highest population demand, which currently comprise family medicine and geriatrics [9,45].
One example of a bottom-up approach was the Québec Health Ministry’s rearrangement of their available residency positions in 2018 to reflect 55% of seats reserved for family medicine, and 45% to all other specialties [46]. In that year alone, there were 65 vacant positions following both iterations of CaRMS Québec family medicine programs [47,48]. In response, the Fédération Médicale Étudiante du Québec (FMEQ) promoted family medicine education under the pretense that disinterest in family medicine stems from the medical students’ lack of knowledge about this specialty [49]. In the following year, there was a drop to 23 vacancies, combined with a greater interest in family medicine demonstrated by an increase from 373 to 440 matched applicants between 2018-2019 in the first iteration [47,50]. The FMEQ approached PRP by targeting and educating medical students about the mix and demand of specialties, particularly with respect to the need for family physicians in the Québec population, with promising outcomes.
Altogether, it could be argued that the strategy to add residency positions after the unmatched CMG peak in 2018 imparted a positive impact on the numbers, but contributed little in terms of addressing the PRP challenges of specialty mix and distribution. Therefore, there is a need to reimagine new PRP strategies after the checkpoint of admission into medical school but prior to participating in the CaRMS match. The goal is to cultivate an interest among medical trainees to choose a specialty which aligns with the quota depicted by the CaRMS checkpoint for admissions to residency.
Role of HHR Platform
Despite efforts occurring at the admissions checkpoints surrounding medical school, which mostly represent top-down PRP approaches, strategies aimed at informing medical students’ specialty choice remains a largely untapped area for effective and large-scale PRP at the national level. Differentiation of the physician body occurs during medical training, thus the decisions made by medical trainees regarding specialty choice have a substantial impact on their nation's health workforce composition. This in turn impacts physician attrition, resource allocation, system sustainability, and favours adequate access to care. The HHR Platform is a bottom-up approach towards improving transparency regarding population health needs and associated practice opportunities to guide medical student specialty choice to be concordant with population health needs.
For example, a medical student user of the HHR Platform who is interested in job prospects for diagnostic radiology in Nova Scotia may notice the decreasing trend for number of physicians and number of job vacancies with higher saturation in the central health region of Nova Scotia. Knowing this type of information for multiple specialties of interest is important in making an informed decision on specialty choice that meets personal needs and those of the population.
The CFMS has approximately 8,300 active medical student members across Canada. With over 2,400 different users in the first four months of the HHR Platform launch, and over 20 daily users on average, there is significant outreach and interest shown by aspiring physicians. The HHR Platform has been designed to become increasingly comprehensive over time, therefore functioning as a reliable and up-to-date Canadian resource for career planning among medical trainees. Future directions include incorporating subspecialty data, additional information about workforce composition and demographics, predictive modelling of physician supply-demand dynamics, and inclusion of allied health professionals into the HHR Platform. Future analyses may be performed to explore how the HHR Platform and population-needs data specifically inform medical student specialty decision-making. The HHR Platform is currently equipped for and awaiting datasets for the projected demand of specialties in 5 or 10 years. This is likely the most anticipated and relevant dataset to inform medical students of societal needs prior to choosing a specialty, and continued advocacy for its public availability is warranted [51].
Limitations
The data amalgamated in the HHR Platform is limited by the inclusion and exclusion criteria of the original datasets, which does not allow for exact comparability. For example, the collection of the datasets are undertaken at different points in time depending on the organization, while in the HHR Platform, they are grouped per annum. Furthermore, the datasets that are available nationally are a result of provincial data collection and sharing, which is not standardized between provinces, and is inconsistent across the various population demographics within Canada [52]. However, the primary limitation remains that the HHR Platform depends on continued public release and sharing of data by the collaborating organizations in a format that is compatible with their previous releases.