In Canada, the number and specialty of physicians is determined by numerous factors including government policies, undergraduate and postgraduate training opportunities, immigration and emigration of providers, gender and age distribution of providers, remuneration incentives and disincentives and the work life cycle of physicians among a host of factors. [7-14] A significant component of the Canadian medical education system is the Canadian Residency Matching Service--CaRMS. CaRMS is a not-for-profit organization that works with the medical education community, medical schools and students, to provide an electronic application service and a computer match for entry into postgraduate medical training that serves all medical students and all postgraduate programs throughout Canada.[15] Canadian medical school training is 4 years at all schools in Canada except two schools where the training lasts 3 years. Students then enter the CaRMS match at the end of this undergraduate medical training. Residencies in Canada for Family Medicine are typically 2 years and for the other specialties they range from 4-5 years. All Canadian medical graduates wishing to enter a residency in Canada participate in CaRMS. The residency match is viewed by medical students as a high stakes activity and students devote significant attention to ensuring that they receive their top choice in the CaRMS match.[16] In 2008, 91% of Canadian medical graduates were matched to their top discipline at the end of the first round of the match.[17]

At present, there is an over-supply of postgraduate medical training positions in Canada for Canadian medical graduates. Even with the inclusion of international medical graduates (IMGs) into the CaRMS process, there were 121 unfilled residency spots in Canada at the end of the second CaRMS match in 2008.[18] As a result, the career preference of Canadian medical graduates has an important impact on the mix of practicing physicians.[19] There is currently no clear national strategy in Canada for discussing the mix of residency positions that should be made available to medical students. This lack of a national strategy at the post-graduate training level coupled with an excess of residency positions means that medical students have a significant role in determining the future mix of providers. Canada is not unique in having a matching service nor an oversupply of postgraduate positions for students which places student choice as an important factor in the mix of future providers. [20,21] Other regions are also moving towards a coordinated national match.[22]

While students do not apply for residency positions until their final year of medical school, for many, the choice between primary care and specialty medicine has been made prior to commencement of or early in medical school. [23-26] For some students, they already have a specific specialty firmly in mind prior to medical school entry.[27] While career choices at medical school entry are clearly mutable, it is clear that these early choices are predictive of ultimate career direction.

Valid survey respondents ranged in age from 19 to 49 years, with a median of 23.0 years and a mean of 24.0 years. A majority of responents were female (56.7%) and single (71.1%) and had entered medical school from a science background (91.7%). Most (75.7%) came from families where their most educated parent had a university education, 41.2% having close family or friends practicing medicine and 20.4% having spent a majority of their childhood living in a rural community (self defined).

The most popular career choice among students at medical school entry was internal medicine and associated medical subspecialties (28.9%), closely followed by family medicine (rural and urban combined, 25.9%). The least popular career choice amongst those listed was psychiatry (2.9%) (See Table ​Table11).

The career interests expressed by students differed significantly from the current mix of full time equivalent physicians for all specialties (p < 0.005) (Table ​(Table22).

This mismatch is greatest for Urban Family Medicine for which the proportion of students interested in this career choice at medical school entry is 28.1% points below the current proportion of physicians practicing in this discipline. There is also discordance between student career choice and the current workforce mix in Psychiatry with student interest 3.7% points below the current proportion of physicians practicing in this discipline. There is a greater interest among entering medical students in the careers of Emergency Medicine (5.0% points greater interest), Internal Medicine and medical subspecialties (4.2% points greater interest), Surgery (7.4% points greater interest) and Paediatrics (11.7% points greater interest) compared to the current proportion of physicians practicing in these areas. There is a near match of the student interest in Obstetrics and Gynaecology (1.2% points greater interest) and Rural Family Medicine (2.4% points greater interest) compared to the current proportion of physicians practicing in these disciplines.

It is likely that the 5% surplus interest in emergency medicine is not an accurate representation of excess interest compared to the current workforce of emergency providers in Canada. CIHI classifies all certificants of the College of Family Physicians of Canada as Family Physicians {both CCFP and CCFP (EM)}. As of May 9 2008, there were 1,796 physicians with a CCFP (EM) designation in the College of Family Physicians of Canada Membership Database. [Personal Communication from Sarah Scott sscott/at/cfpc.ca, National Physician Survey & Janus Project Coordinator, College of Family Physicians of Canada to Ian Scott, May 9, 2008)] Chan [32] estimates that 50% of physicians with CCFP (EM) designation practice primarily emergency medicine. Others have found even higher numbers CCFP (EM) physicians practicing primarily emergency medicine with less than 20% engaged in a blended family/emergency medicine practice.[33] In addition, in many rural or remote jurisdictions physicians practice emergency medicine without any form of certification. Thus, the actual excess interest in emergency medicine compared to actual providers of emergency care may be smaller than is observed if one were able to compare student interest with the actual numbers of physicians providing emergency care across Canada.

The impact of the number of international medical graduates (IMGs) who enter the system at the level of the CaRMS match is modest but growing. During the 2008 CaRMS match, IMGs (who were Canadian Citizens or Landed Immigrants) accounted for 14.2% (353) of the total residency positions filled (2478). [Personal Communication email from Jim Boone jboone/at/carms.ca General Manager and COO, CaRMS to Ian Scott January 22, 2009] Overall the national percentage of IMGs within the Canadian medical workforce has declined slightly from 23.1% in 2000 to 22.3% in 2004.[34]

Our study shows nearly the same proportion of graduates interested in practicing rural family medicine as are currently providing service in rural communities. However, this is already an under-serviced geographical area. Rourke estimates that an additional 1175 family physicians are required to bring the family physician-population ratio to the same level as the Canadian average.[35]

This study begs the question: "What is the appropriate mix of physician specialities for Canada?". While a number of organizations, commissions and reports [36-41] have looked at this issue, there are as yet no clear recommendations. There have been calls for greater systematic centralized physician data collection but these calls have not yet been heeded.[42] Recently the Canadian Medical Association Journal requested human resources data from the College of Family Physicians of Canada and all 47 specialty groups registered with the Royal College of Physicians and Surgeons of Canada.[43] Only 27 groups responded to the request and of those who responded, only 13 had done studies over the last decade on the health human resources issues in their discipline.[43] Of those that had done studies, only six could quantify existing shortages of physicians in their specific discipline. With over 4,000 physicians planning to retire or leave practice in the next 2 years, the current number of Canadian medical graduates barely fills this void particularly given the entering cohort's career intentions.[8]

Given that there is evidence that student interest at career entry is associated with a student's ultimate career choice [23-27], this data gives insight into not only the future career aspirations of medical students but the possible future structure and function of the Canadian Health Care System. This study therefore heralds a future Canadian Health Care system populated by increasing numbers of specialists, decreasing numbers of urban family physicians and the on-going insufficient number of rural family physicians.

Since medical educators have a social responsibility to be accountable for the health care needs of the population they serve [44], it may be time to selectively recruit students and to modify medical school curricula in such a way as to better meet the future needs of Canada's population. An alternative solution would be to limit the number of postgraduate positions in certain disciplines to drive students towards the required career choices. Such a strategy may result in many students finding themselves in careers they are not suited for or students choosing to move to other jurisdictions for postgraduate training to achieve their desired career choices. Both of these outcomes could have negative implications for the Canadian Health Care System.