Postgraduate training in Canada.

Abstract

In contrast to the United Kingdom, postgraduate medical training in Canada is entirely confined to university settings although it was not always so. Excellent reviews of the historical background have been published by Shephard' and Ruedy.2 Specialty intern and residency (the term used in North America for housestaff and registrar positions) training in Canada first became popular in the 1920s and 1930s when medical graduates began to seek a year of hospital training before entering practice. The term 'intern' was first introduced at Johns Hopkins University when the first graduates sought hospital positions in 1897 where Osler refined this internship role based on his previous experience at McGill University in Montreal, Canada. Prior to 1972 residents were primarily involved in the care of those patients without private insurance but the introduction ofMedicare (the equivalent ofthe National Health Service in the United Kingdom) resulted in a much larger pool of patients available in the teaching hospitals for training. This also meant that it became possible for all postgraduate training to be university based; this was decided upon by the Royal College because (a) teaching hospitals affiliated with medical schools were found to be better equipped and staffed to provide comprehensive training within a speciality; (b) it is easier to ensure that someone (the university) takes responsibility for the residents overall training instead ofthe resident having to seek a series of appointments often at different hospitals. Whereas in 1959 47 hospitals out of 140 offered residencies without any connection to universities, in 1975 it became obligatory that all programmes be university based. Initially, specialization was opposed by many in the profession since specialists were self-designated, but it became quickly accepted once guidelines for training and evaluation were put in place. In Canada, the Royal College of Physicians was founded so that any physician wanting to perform 'special work' would have the opportunity to obtain a 'distinguishing designation'.' Since 1946 certification as a specialist has required the passing of standardized assessments and examinations; in 1971 it was decided that certification should evaluate competence by setting clear-cut examination objectives that matched the training objectives and that evaluation should occur over the duration of the whole training instead of totally depending upon a short, one-shot exam; this was implemented by introducing a mid-training examination of the candidates' knowledge of the general principles with a later examination of the candidates' knowledge of a particular specialty and the inclusion of information from the assessment of a candidates' in-training evaluation reports. Most residency programmes are based on residents gaining experience in the care ofin-patients on Clinical Teaching Units (CTUs) which are organised to focus on the training of residents and senior medical students. There is now increasing emphasis on the extension of the CTU to day care units and ambulatory clinics where an increasing proportion of specialty medicine often involving the application of high technology, such as endoscopy and body imaging, is being carried out without admission to hospital. Unfortunately postgraduate training programmes are becoming a political battleground in Canada due to the provincial governments (healthcare is primarily a provincial rather than a federal responsibility) using a programme of systematic reduction of residency positions by as much as 50% in some cases to reduce the number of specialist physicians who are deemed to be in oversupply. This is causing increasing problems because the residents have traditionally provided the service coverage for teaching hospitals and the supervision of medical students the quality of the training clearly markedly diminishes as the number of specialty residents drops to one or two who are responsible for increasing clinical loads and supervision ofstudents. It is bad for the educational focus when these trainees become the political pawns and the residency programme becomes the villain when decisions have to be made to withdraw residents from some clinical services. Expansion of the number of specialty residency training programmes has accentuated this