Canadian Medical Graduates Research Articles

Recruitment and retention of physicians in rural Alberta: the spousal perspective

The overall geographic distribution of physicians in Canada, including Alberta, is misaligned with the population distribution. Some strategies, such as debt repayment, are currently in practice to increase recruitment and retention of physicians in rural locations. Of the factors influencing choice of practice location, 'spousal influence' is considered to play a significant role in recruitment and retention of physicians in literature. Most studies have focused on the physicians' perspective of their spouses' influence on staying in a rural location. This study is unique as it approaches rural recruitment and retention from the perspective of the physician spouse. The physician population for this study consisted of doctors practicing in rural southern Alberta. Participants were recruited via an email invitation and were invited to complete an online survey. The survey collected information regarding physician demographics and some relationship characteristics. The email invitation also contained a link to a second survey specific to the physician spouse or partner, asking a similar panel of questions. Physicians were asked to request their spouse or partner to complete this survey. Semi-structured interviews were conducted for those who consented to be contacted for interviews. Descriptive statistical analysis of the survey data was carried out. Thematic analysis of the qualitative interview data was conducted and was organized into three sections. The first and second sections present the personal experiences of rural recruitment and rural retention. The third section presents recommendations made by physicians and spouses to improve these processes. Specific interview quotes led the authors to derive themes under each section. The results of this study raise the voice and profile of the spouse in the process of rural recruitment and retention. In this study, the spouses of Canadian medical graduates were a positive influence in rural recruitment and retention, while the spouses of international medical graduates were generally less supportive of a rural lifestyle. Considerations to accommodate the educational, professional and cultural needs of the physician spouse must be incorporated into policy if large areas of underserved rural communities will continue to rely on international recruitment.

Using Automatic Item Generation to Improve the Quality of MCQ Distractors

ABSTRACTConstruct: Automatic item generation (AIG) is an alternative method for producing large numbers of test items that integrate cognitive modeling with computer technology to systematically generate multiple-choice questions (MCQs). The purpose of our study is to describe and validate a method of generating plausible but incorrect distractors. Initial applications of AIG demonstrated its effectiveness in producing test items. However, expert review of the initial items identified a key limitation where the generation of implausible incorrect options, or distractors, might limit the applicability of items in real testing situations. Background: Medical educators require development of test items in large quantities to facilitate the continual assessment of student knowledge. Traditional item development processes are time-consuming and resource intensive. Studies have validated the quality of generated items through content expert review. However, no study has yet documented how generated items perform in a test administration. Moreover, no study has yet to validate AIG through student responses to generated test items. Approach: To validate our refined AIG method in generating plausible distractors, we collected psychometric evidence from a field test of the generated test items. A three-step process was used to generate test items in the area of jaundice. At least 455 Canadian and international medical graduates responded to each of the 13 generated items embedded in a high-stake exam administration. Item difficulty, discrimination, and index of discrimination estimates were calculated for the correct option as well as each distractor. Results: Item analysis results for the correct options suggest that the generated items measured candidate performances across a range of ability levels while providing a consistent level of discrimination for each item. Results for the distractors reveal that the generated items differentiated the low- from the high-performing candidates. Conclusions: Previous research on AIG highlighted how this item development method can be used to produce high-quality stems and correct options for MCQ exams. The purpose of the current study was to describe, illustrate, and evaluate a method for modeling plausible but incorrect options. Evidence provided in this study demonstrates that AIG can produce psychometrically sound test items. More important, by adapting the distractors to match the unique features presented in the stem and correct option, the generation of MCQs using automated procedure has the potential to produce plausible distractors and yield large numbers of high-quality items for medical education.

Residents: admissions, training and assessment

Undoubtedly, residents play a very important role in the healthcare system of most countries. The process of admission of medical trainees into specialties, residency training and their assessment are key determinants of the future of healthcare. In Canada, according to the 2014–15 data, there were 13,439 residents (excluding Fellows) distributed in 42 specialties/sub-specialities.1 Every year, there are 3,280 positions in Canada. About 10% of these residents are International Medical Graduates (IMGs) or Canadians studying abroad (CSAs). Residents are subjects of various investigations exploring areas such as sleep deprivation, stress,2 medication errors to differences between Canadian Medical graduates (CMGs), IMGs and CSAs that can help with decisions of policy makers.3 Here I dwell on a two interesting examples of studies using residents as subjects. Philips and Barker who systematically examined the occurrence of fatal medication errors over 25 years in the US attribute a significant spike in medication errors in July to the entry of a new cohort of medical residents.3 Can changes in medical education have an impact on such medication errors? While this needs to be investigated, better orientation of final year medical students for entry into residency, closer supervision of new residents, and training of supervisors on providing feedback to residents are some measures that ought to be seriously considered. The introduction of Competency by Design (CBD) by the Royal College of Physicians and Surgeons is definitely an important step in this direction.4 A recent study by Curtis and Dube looked at the characteristics of CMGs, IMGs and CSAs in an era where measures are being taken to alleviate physician shortage.5 IMGs make up about 25% of practicing physicians in Canada. However, the scenario is changing, with more CSAs applying for residency positions. As of 2014, there were 3600 CSAs. These findings in particular have implications for policy: IMGs are less likely than CMGs to report that they intend to stay and practice in Canada; CSAs are less likely to report their willingness to practice in the region where they completed their residency. CSAs and IMGs are more likely to choose family medicine than CMGs. Given the paucity of residency positions in Royal College specialties, and less inclination of CMGs to choose family medicine, do changes have to be made to admit more CSAs and IMGs to fill family medicine positions? If that is done, how can IMGs be enticed to practice in Canadian regions where physicians are most needed? IMGs and CSAs are less likely to be females. How will this impact the diversity and equality that Canada tries to promote? These are interesting and complex questions that arise from the study.

Demographics, Debt, and Practice Intentions of Medical Residents Training in Canada

Many international medical graduates (IMGs) are unable to find residency positions in Canada. A growing proportion are “Canadians studying abroad” (CSAs) trying to return to Canada. We examine the characteristics and practice intentions of residents in Canada: IMGs excluding CSAs, CSAs, and Canadian medical school graduates (CMGs). CSAs and CMGs appear to be similar, but IMGs do not in key instances. IMGs are substantially less likely to state that they intend to practise where they trained or in Canada, controlling for characteristics. This adds support to previous findings indicating that regions relying on IMGs to provide health care may experience ongoing challenges.

Best-fit model of exploratory and confirmatory factor analysis of the 2010 Medical Council of Canada Qualifying Examination Part I clinical decision-making cases.

Purpose:This study aims to assess the fit of a number of exploratory and confirmatory factor analysis models to the 2010 Medical Council of Canada Qualifying Examination Part I (MCCQE1) clinical decision-making (CDM) cases. The outcomes of this study have important implications for a range of domains, including scoring and test development.Methods:The examinees included all first-time Canadian medical graduates and international medical graduates who took the MCCQE1 in spring or fall 2010. The fit of one- to five-factor exploratory models was assessed for the item response matrix of the 2010 CDM cases. Five confirmatory factor analytic models were also examined with the same CDM response matrix. The structural equation modeling software program Mplus was used for all analyses.Results:Out of the five exploratory factor analytic models that were evaluated, a three-factor model provided the best fit. Factor 1 loaded on three medicine cases, two obstetrics and gynecology cases, and two orthopedic surgery cases. Factor 2 corresponded to pediatrics, and the third factor loaded on psychiatry cases. Among the five confirmatory factor analysis models examined in this study, three- and four-factor lifespan period models and the five-factor discipline models provided the best fit.Conclusion:The results suggest that knowledge of broad disciplinary domains best account for performance on CDM cases. In test development, particular effort should be placed on developing CDM cases according to broad discipline and patient age domains; CDM testlets should be assembled largely using the criteria of discipline and age.

In-group bias in residency selection

Background: More than half of all Canadian medical graduates match to residency programs within the same university as their medical school. Here we describe two studies designed to explore whether there is partiality for internal applicants in the resident selection process.Methods: We first performed an observational study in which we compared the ratings of 14 ‘internal’ and 89 ‘external’ applicants to the University of Calgary Internal Medicine Training Program by resident and faculty raters. Following this we then asked residents to rate anonymous application packages in which we manipulated applicants’ affiliation to our training program.Results: In our first study, we found that residents rated internal applicants significantly higher for both application packages (mean (SD)) rating for internal versus external applicants (4.86 (0.36) vs. 4.36 (0.57), d = 1.05, p = 0.002) and interviews (4.93 (0.27) vs. 4.36 (0.7), d = 1.07, p = 0.003). There was no difference in the faculty ratings of internal and external applicants. In our second study, we found that residents rated applicants with an affiliation to our program – either attending the local medical school or having completed an elective – higher than applicants with no affiliation to our program.Conclusions: Our finding support in-group bias during resident selection, possibly due to the interdependent relationship between residents and students. Considering the career implications of residency matching, we feel that further studies are needed to identify and mitigate sources of bias in the residency application process.

Within-Session Score Gains for Repeat Examinees on a Standardized Patient Examination

Previous studies on standardized patient (SP) exams reported score gains both across attempts when examinees failed and retook the exam and over multiple SP encounters within a single exam session. The authors analyzed the within-session score gains of examinees who repeated the United States Medical Licensing Examination Step 2 Clinical Skills to answer two questions: How much do scores increase within a session? Can the pattern of increasing first-attempt scores account for across-session score gains? Data included encounter-level scores for 2,165 U.S. and Canadian medical students and graduates who took Step 2 Clinical Skills twice between April 1, 2005 and December 31, 2010. The authors modeled examinees' score patterns using smoothing and regression techniques and applied statistical tests to determine whether the patterns were the same or different across attempts. In addition, they tested whether any across-session score gains could be explained by the first-attempt within-session score trajectory. For the first and second attempts, the authors attributed examinees' within-session score gains to a pattern of score increases over the first three to six SP encounters followed by a leveling off. Model predictions revealed that the authors could not attribute the across-session score gains to the first-attempt within-session score gains. The within-session score gains over the first three to six SP encounters of both attempts indicate that there is a temporary "warm-up" effect on performance that "resets" between attempts. Across-session gains are not due to this warm-up effect and likely reflect true improvement in performance.

To specialize or too specialized?

In January of 2011 I, together with my fourth-year medical student colleagues, returned to the University of Western Ontario from our electives to begin four months of preparation for our medical licensing exam. During large group discussions on general clinical scenarios, it was clear that, for most students, specialization was well underway. When listing a differential diagnosis for a headache, the budding emergency physician saw a subarachnoid hemorrhage, the future family physician saw migraines, and the soon to be obstetrician/gynecologist saw preeclampsia. Before completing our “general practice” training, it was evident that many of us were already too committed to specialization to become general clinicians. The 16 weeks of elective time we recently completed marked the first opportunity to customize our medical education. Students used their elective time to demonstrate a commitment to general practice or to their chosen specialties and to improve their knowledge of general medicine. Many students applying for Royal College specialty training programs had spent over half of their elective time (in some cases up to 12 weeks) on a single specialty service. Since 1996, Canadian medical students apply through the Canadian Residency Matching Service in September of their 4th year (or 3rd year in a 3-year medical school curriculum)1. This tight timeline pressures many students applying to competitive specialties to decide on their specific career aspirations early on during their medical training, as applicants commonly perceive that residency program selection committees view a high proportion of electives in one specialty and specialty-specific research projects as appealing assets in a candidate. In many circumstances, students are committing to specialties prior to completing all their core clerkship rotations. The current system introduces two important conditions of great concern: 1) Students are required to commit to specialties too early, 2) Latter medical school training is now weighted towards specialization and away from mastering general medicine. Until the 1990s, Canadian medical graduates entered a rotating internship before beginning general practice or applying for specialty programs.2 Advantages to the rotating internship included better familiarity with in-patient medicine and the ability to explore diverse fields of medicine prior to committing to a specialty.3 During the rotating internship era, 17.5% of Canada’s 1989 graduating class changed their choice of specialty after commencing residency.4 In Saskatchewan in 1994, 59% of survey respondents were practicing in a field different from the one they planned in their second-last year of medical school.5 However, in the 1980s, several reports recommended creating a different training program for family physicians instead of relying on the rotating internship. By 1993, all provinces had embraced a 2-year family medicine residency program and abandoned the rotating internship.6 Some Royal College programs then incorporated the rotating internship into their first year of training.6 Deciding on a specialty too early may lead to discontent with a resident’s chosen specialty. After abandoning the rotating internship, in 1995, 40% of graduating medical students felt poorly to moderately prepared to choose a residency and 7% of students reported they would like to change their chosen specialties after the match.6,7 The significant proportion of students who are unsure of their choice is especially concerning. Given that the current residency application system is unlikely to change, medical schools should focus on providing students with a broad range of clinical exposures earlier in the first two years. In addition, clerkship programs should be structured to maximize students’ exposure to the major specialties prior to requiring commitment to a specific career. Medical students use the final year of medical school to make themselves appealing candidates for residency programs. Specialty programs seem to prefer medical students who have already committed to specialization by dedicating a high proportion of their elective time to one field. The current system does not favor the applicant who is undecided (and perhaps open-minded) and wishes to use their elective time to explore various fields in medicine to facilitate a good decision. Abolishing the rotating internship created an environment where specialty candidates use the medical school experience as a means to gain entrance into specialty programs. The emphasis on becoming a competitive applicant for a specialty has diminished medical students’ opportunities to master general medicine. The current system raises a critical question: if residency programs train specialists, are medical schools already too specialized to focus on training general doctors first?

Performance on the American Board of Family Medicine Certification Examination by Country of Medical Training

Performance on the American Board of Family Medicine (ABFM) Certification and Recertification Examinations by country of medical school training has not been examined. Based on internal medicine patterns, we hypothesize that examinees trained in the United States and Canada would outperform examinees trained in other countries. In this retrospective cohort study from 2004 to 2011, data on the ABFM examinations were obtained from the ABFM. Fisher exact and χ(2) tests were performed across years based on the country of examinee training. Simple linear regression was performed to evaluate pass rates over time. All statistics were performed using an α = 0.05. The overall pass rate over the study period was 84.4% (74,821 of 88,680). The pass rate for US medical graduates (USMGs) was 88.3% (60,328 of 68,332). The pass rate for Canadian medical graduates (CMGs) was 93.8% (872 of 930). The pass rate for non-Canadian foreign medical gradates (NC-FMGs) was 70.1% (13,621 of 19,418). CMGs had a higher pass rate than USMGs (P < .001) and NC-FMGs (P < .001). Simple linear regression showed significant decreasing trends over time for all examinees (P = .02), for USMGs (P = .02), and for CMGs (P = .02). USMGs and CMGs outperform NC-FMGs on the ABFM certification and recertification examinations. These findings may alter acceptance patterns for Family Medicine residency programs.

Stability of Medical Student Career Interest

To examine the stability and switching patterns of student career interests over the course of medical school. From 2001 through 2004, during the first two weeks of classes, a survey on career interest was distributed to first-year students in 15 classes at eight Canadian medical schools. Students indicated interest in eight broad career paths (emergency medicine, family medicine, internal medicine, obstetrics-gynecology, pediatrics, psychiatry, surgery, and "other") and ranked their top three. Following these students' residency match three to four years later, student residency career choice was linked to their career interest at medical school entry. For students whose career interests switched be-tween medical school entry and exit, switching patterns were examined in terms of careers' matching difficulty scores (MDSs). Of 1,941 eligible students, 1,542 contributed to the final analysis. Family medicine, internal medicine, and surgery had the greatest student interest at both the beginning and end of medical school. Family medicine, surgery, obstetrics-gynecology, psychiatry, and "other" careers showed a net gain of student interest during medical school with the remaining careers showing a loss of interest. The most stable careers were family medicine, surgery, and internal medicine. The least stable were pediatrics and obstetrics-gynecology. Students tended to switch between careers with similar MDSs. Student career choice is relatively stable with a number of careers showing approximately 50% of stability from the entrance to the exit of medical school. Students tend to switch to careers with similar MDS, but some specific switching patterns exist.

Multiple Mini Interview for Selection into OTL Residency

Objective: 1) To determine the reliability of the Multiple Mini Interview (MMI) for resident selection into an otolaryngology–head and neck surgery (OTL-HNS) program. 2) To assess the degree of acceptance by major stakeholders (interviewers and applicants) towards the MMI when compared to traditional interviews. Method: Canadian medical graduates applying to OTL-HNS residency programs underwent MMI in 2011 and 2012. MMI had 7 stations evaluating unique candidate attributes. Stations include surgical skills assessment and 2 simulation scenarios with standardized actors for noncognitive traits. Reliability was determined, and upon completion, stakeholders rated aspects MMI using 7-point Likert scale. Results: Data were collected from a total of 45 applicants and 19 evaluators. Overall interrater reliability of the MMI was good. The majority of applicants (&gt;80%) felt that MMI helped them present their strengths and that it did not have any gender, cultural, or age bias. Assessors (&gt;85%) felt that the MMI evaluated a valid range of competencies and that it tested more aspects of an applicant than traditional interviews. Both applicants and assessors (&gt;70%) agreed that the MMI was a fair process, and both preferred the MMI over the traditional interview. Conclusion: The MMI is a reliable tool for the selection of applicants to an OTL-HNS residency program. It is well accepted by both applicants and assessors, with the majority of stakeholders preferring the MMI over traditional interviews.

The Relationship Between Response Time and Diagnostic Accuracy

Psychologists theorize that cognitive reasoning involves two distinct processes: System 1, which is rapid, unconscious, and contextual, and System 2, which is slow, logical, and rational. According to the literature, diagnostic errors arise primarily from System 1 reasoning, and therefore they are associated with rapid diagnosis. This study tested whether accuracy is associated with shorter or longer times to diagnosis. Immediately after the 2010 administration of the Medical Council of Canada Qualifying Examination (MCCQE) Part II at three test centers, the authors recruited participants, who read and diagnosed a series of 25 written cases of varying difficulty. The authors computed accuracy and response time (RT) for each case. Seventy-five Canadian medical graduates (of 95 potential participants) participated. The overall correlation between RT and accuracy was -0.54; accuracy, then, was strongly associated with more rapid RT. This negative relationship with RT held for 23 of 25 cases individually and overall when the authors controlled for participants' knowledge, as judged by their MCCQE Part I and II scores. For 19 of 25 cases, accuracy on each case was positively related to experience with that specific diagnosis. A participant's performance on the test overall was significantly correlated with his or her performance on both the MCCQE Part I and II. These results are inconsistent with clinical reasoning models that presume that System 1 reasoning is necessarily more error prone than System 2. These results suggest instead that rapid diagnosis is accurate and relates to other measures of competence.

Family medicine graduates' perceptions of intimidation, harassment, and discrimination during residency training

BackgroundDespite there being considerable literature documenting learner distress and perceptions of mistreatment in medical education settings, these concerns have not been explored in-depth in Canadian family medicine residency programs. The purpose of the study was to examine intimidation, harassment and/or discrimination (IHD) as reported by Alberta family medicine graduates during their two-year residency program.MethodsA retrospective questionnaire survey was conducted of all (n = 377) family medicine graduates from the University of Alberta and University of Calgary who completed residency training during 2001-2005. The frequency, type, source, and perceived basis of IHD were examined by gender, age, and Canadian vs international medical graduate. Descriptive data analysis (frequency, crosstabs), Chi-square, Fisher's Exact test, analysis of variance, and logistic regression were used as appropriate.ResultsOf 377 graduates, 242 (64.2%) responded to the survey, with 44.7% reporting they had experienced IHD while a resident. The most frequent type of IHD experienced was in the form of inappropriate verbal comments (94.3%), followed by work as punishment (27.6%). The main sources of IHD were specialist physicians (77.1%), hospital nurses (54.3%), specialty residents (45.7%), and patients (35.2%). The primary basis for IHD was perceived to be gender (26.7%), followed by ethnicity (16.2%), and culture (9.5%). A significantly greater proportion of males (38.6%) than females (20.0%) experienced IHD in the form of work as punishment. While a similar proportion of Canadian (46.1%) and international medical graduates (IMGs) (41.0%) experienced IHD, a significantly greater proportion of IMGs perceived ethnicity, culture, or language to be the basis of IHD.ConclusionsPerceptions of IHD are prevalent among family medicine graduates. Residency programs should explicitly recognize and robustly address all IHD concerns.

Social disparities in the use of colonoscopy by primary care physicians in Ontario

BackgroundIt is unclear if all persons in Ontario have equal access to colonoscopy. This research was designed to describe long-term trends in the use of colonoscopy by primary care physicians (PCPs) in Ontario, and to determine whether PCP characteristics influence the use of colonoscopy.MethodsWe conducted a population-based retrospective study of PCPs in Ontario between the years 1996-2005. Using administrative data we identified a screen-eligible group of patients aged 50-74 years in Ontario. These patients were linked to the PCP who provided the most continuous care to them during each year. We determined the use of any colonoscopy among these patients. We calculated the rate of colonoscopy for each PCP as the number of patients undergoing colonoscopies per 100 screen eligible patients. Negative binomial regression was used to identify factors associated with the rate of colonoscopy, using generalized estimating equations to account for clustering of patients within PCPs.ResultsBetween 7,955 and 8,419 PCPs in Ontario per year (median age 43 years) had at least 10 eligible patients in their practices. The use of colonoscopy by PCPs increased sharply in Ontario during the study period, from a median rate of 1.51 [inter quartile range (IQR) 0.57-2.62] per 100 screen eligible patients in 1996 to 4.71 (IQR 2.70-7.53) in 2005. There was substantial variation between PCPs in their use of colonoscopy. PCPs who were Canadian medical graduates and with more years of experience were more likely to use colonoscopy after adjusting for their patient characteristics. PCPs were more likely to use colonoscopy if their patient populations were predominantly women, older, had more illnesses, and if their patients resided in less marginalized neighborhoods (lower unemployment, fewer immigrants, higher income, higher education, and higher English/French fluency).ConclusionsThere is substantial variation in the use of colonoscopy by PCPs, and this variation has increased as the overall use of colonoscopy increased over time. PCPs whose patients were more marginalized were less likely to use colonoscopy, suggesting that there are inequities in access.

Comparison of Canadian Medical Graduates and International Medical Graduates in Canada: 1989–2007

To compare Canadian medical graduates (CMGs) and international medical graduates (IMGs) who completed postgraduate medical education in Canada from 1989 to 2007 by age, gender, specialty, and practice characteristics. Data on all CMGs and IMGs who completed residencies or fellowships in Canada from 1989 to 2007 were extracted from the Canadian Post-M.D. Education Registry. Data from 1989-1993 and 2003-2007 were pooled for analysis. A total of 8,501 CMGs and 1,828 IMGs completed post-MD training at Canadian institutions between 1989 and 1993 inclusive; 7,734 CMGs and 1,879 IMGs completed such training between 2003 and 2007. From 1989-1993 to 2003-2007, the average age of CMGs increased from 29.8 to 31.1 years, and average age of IMGs increased from 36.1 to 37.0 years. From 1989-1993 to 2003-2007, the percentage of women increased from 41% (3,471/8,501) to 52% (4,016/7,734) and from 28% (509/1,828) to 42% (791/1,879) for CMGs and IMGs, respectively. The proportion of CMGs who trained in family medicine declined from 54% (4,568/8,501) to 38% (2,921/7,734) from 1989-1993 to 2003-2007. The percentage of IMGs who trained in family medicine increased from 19% (344/1,828) to 37% (699/1,879) during the same period. IMGs tended to be older, more likely to be men, and more likely to pursue family medicine than their CMG counterparts. These differences have implications in designing future health care policy and recruiting physicians from abroad. Other countries could look at their own physician demographics using this study's methods.

The Reliability and Acceptability of the Multiple Mini-Interview as a Selection Instrument for Postgraduate Admissions

The Multiple Mini-Interview (MMI) is useful in selecting undergraduate medical trainees. Postgraduate applicant pools have smaller numbers of more homogeneous candidates that must be actively recruited while being assessed. This paper reports on the MMI's use in assessing residency candidates. Canadian and international medical graduates to three residency programs--obstetrics-gynecology and pediatrics (McMaster University) and internal medicine (University of Alberta)--underwent the MMI for residency selection (n = 484) in 2008 and 2009. Reliability was determined and candidates and interviewers completed an exit survey assessing acceptability. Overall reliability of the MMI was acceptable, ranging from 0.55 to 0.72. Using 10 stations would increase reliability to 0.64-0.79. Eighty-eight percent of candidates believed they could accurately portray themselves, while 90% of interviewers believed they could reasonably judge candidates' abilities. The MMI provides a reliable way to assess residency candidates that is acceptable to both candidates and assessors across a variety of programs.

How clinical features are presented matters to weaker diagnosticians

This study aimed to test the extent to which the use of medicalese (i.e. formal medical terminology and semantic qualifiers) alters the test performance of medical graduates; to tease apart the extent to which any observed differences are driven by language difficulties versus differences in medical knowledge; and to assess the impact of varying the language used to present clinical features on the ability of the test to consistently discriminate between candidates. Six clinical cases were manipulated in the context of pilot items on the Canadian national qualifying examination. Features indicative of two diagnoses were presented uniformly in lay terms, medical terminology and semantic qualifiers, respectively, and in mixed combinations (e.g. features of one diagnosis were presented using lay terminology and features of the other using medicalese). The rate at which the indicated diagnoses were named was considered as a function of language used, site of training, birthplace and medical knowledge (as measured by overall performance on the examination). In the mixed conditions, Canadian medical graduates were not influenced by the language used to present the cases, whereas international medical graduates (IMGs) were more likely to favour the diagnosis associated with medical terminology relative to that associated with lay terms. This was true regardless of whether the entire sample or only North American-born candidates were considered. Within the IMG cohort, high performers were not influenced by the language manipulation, whereas low performers were. Uniform use of lay terminology resulted in the highest test reliability compared with the other experimental conditions. The results indicate that the influence of medical terminology is driven more by substandard medical knowledge than by the language issues that challenge some candidates. Implications for both the assessment and education of medical professionals are discussed.

Higher percentage of medical school graduates seek family medicine residencies

A third of Canadian medical school graduates have chosen family medicine for their residencies, a percentage that primary care advocates say is good but still not good enough. “I think we would be a lot more comfortable if we reached 40%,” says Dr. Cathy MacLean, president of the College of

The Psychiatry Institute for Medical Students: A Decade of Success

Recruiting medical students into psychiatric residency programs has received much attention. In the 1980s and 1990s, North American psychiatric residency programs experienced numerous barriers to recruiting highquality medical students (1–5). This remains a problem around the world. The literature suggests that experiences during medical school, personalities of applicants, and beliefs about the practice of psychiatry are all strongly associated with the decision to enter a psychiatric residency. Recruitment strategies have been widely recommended to bolster positive psychiatry-related experiences and to alter negative perceptions (6–9). In the mid-1990s, only about 4% of U.S. and 6% of Canadian medical school graduates chose psychiatry (10, 11). More recent studies focused on perceptions and attitudes of medical students about psychiatry careers (12– 17). While initial interest is still the most influential factor, positive experiences during psychiatry clerkships and electives have been described as “modifiable programmatic factors that could enhance recruitment to psychiatry” (17). The Psychiatry Institute for Medical Students at the University of Toronto in Ontario was initiated in 1994 as a novel recruitment strategy (18). To our knowledge, similar programs have not been reported. As an indication of how much the recruitment situation has changed in Toronto, the 2008 Canadian Resident Matching Service match was successful in filling all 28 postgraduate year 1 (PGY-1) psychiatric residency positions at the University of Toronto as well as two international medical graduate positions—a total of 30 spots, up from 24 spots 2 years ago (19). As of July 2007, the University of Toronto has 138 psychiatric residents from PGY-1 to PGY-5.

Undergraduate Otolaryngology Education in Canadian Medical Schools

To examine the quantity and nature of undergraduate otolaryngology instruction in the Canadian medical school system and to present the management of the undergraduate otolaryngology curriculum at the University of Toronto medical school with a yearly enrolment of 224 students. Survey questionnaire and narrative description. A structured one-page survey was administered to the education directors of all 16 Canadian medical schools. The administration of core learning material, scheduling, patient encounter logging, and student and instructor evaluations with computerized, on-line systems at the University of Toronto was described. Rotations in otolaryngology were highly variable across medical schools. Mandatory rotations in otolaryngology were identified in only 6 of the 16 undergraduate curricula. The average length of clinical experience in schools with mandatory rotations was 4.6 days. The majority of Canadian medical graduates complete their undergraduate training with minimal clinical experience in otolaryngology. There is a clear discrepancy between the quantity and perceived need for training. To provide a thorough and equitable exposure to otolaryngology, a curriculum with standardized lectures and evaluation procedures is required.