Canadian medical students’ interest in pursuing careers in research, education and administration is on the rise, signalling future physicians’ interest in enhancing the health-care system rather than simply being a part of it.
It is often assumed that the primary goal of Canadian medical education, and the aspiration of those students, is to produce clinicians who provide care in a variety of medical disciplines. Medical schools also must prepare future physicians to fill roles as educators, researchers and administrators to ensure the Canadian medical system continues to advance, support and lead. Understanding the career interests and intentions of Canadian medical students allows medical schools to provide appropriate training and helps inform the direction of health care.
The Association of Faculties of Medicine of Canada (AFMC) delivers questionnaires in most of Canada’s medical schools, including the 17 Academic Health Sciences Centres (AHSC) and 22 Distributed Medical Education (DME) campuses. The questionnaires are considered valuable by medical schools, especially in their medical education accreditation surveys. The AFMC questionnaires are among the only methods of systematically gathering information about student experiences in Canadian MD education programs. AFMC surveys produce detailed information at entry, prior to starting clinical rotations and at the end of medical school. The entry questionnaire includes a question regarding “career intention” on respondents’ career plans.
In both AHSC and their geographically separate DME campuses, responses to the career intention question significantly changed after 2019 (see attached Table 1). There was high reported intention of clinical practice in 2019 that fell considerably in 2020 and 2021 at both AHSC and DME campuses (see Table 1). Meanwhile, the intent to pursue Research/Science, Education and Administration by students at both AHSC and DME campuses significantly increased (see Table 1).
One of the influences on this change may be changes to post-graduate residency specialty program descriptions in Canada’s medical schools reported in the Canadian Resident Matching Service (CaRMS). In 2020, CaRMS for the first time asked residency programs to describe explicitly their expectations of scholarly activity in their CaRMS website profiles. Before 2020, CaRMS provided little guidance to applicants about reporting scholarly activities in their applications.
The increase in career intentions in scholarship (research/science and education) may also be influenced by increasing interest in non-clinical career options in the post-pandemic environment and increasing dissatisfaction with clinical practice among Canadian physicians.
Given the shift in career intentions, it is important for medical schools to consider the access students have to a range of scholarly activity in their home campuses that are in alignment with the Canadian Medical Education Directives for Specialists (CanMEDS). CanMEDS states that scholarly activity is an essential competency of practicing physicians and recommends scholarly activity be a mandatory component of physician education in addition to six other core competencies: medical expert, communicator, collaborator, manager, health advocate and professional.
These essential competencies raise questions about what constitutes research and scholarship. Scholarly activities include more than traditional research. Consistent with valuing inquisitiveness, quality improvement of health services and medical education research qualify as scholarly activities. Scholarly activities also can include organized evidence-based clinical discussions, podcasts or social-media initiatives.
Scholarly activities include more than traditional research.
To obtain a deeper understanding of these new findings about career interests, we recommend the AFMC inquire how students choose their career paths and what training and employment opportunities will allow them to achieve their goals. To do so, the AFMC could follow a panel of students through their time in medical school to determine cause and effect relationships – for example, the effects of clinical learning experiences, general skills, preparedness for residency, research opportunities, mistreatment and financial information on attitudes towards scholarly activity. We also suggest that AFMC include items in its questionnaires that would be sensitive to change over students’ time in medical school. Observations made repeatedly at individual levels can be more influential than cross-sectional studies.
As there is a lack of consensus on how to measure engagement in scholarly activity, other questions may more accurately tap into this activity in the questionnaires. There are few reports about formal evaluation of scholarly activity engagement in medical education programs. Information produced by the AFMC questionnaires can be used to identify topics requiring other methods to better understand the questionnaire findings. For example, the shift of career intent to research/science and education could be examined by qualitative research studies using focus groups involving faculty and students.
The shift in career intentions is encouraging as it will result in more trainees engaged in, and not detached from, scholarly activities. The types of “science” that physicians engage in has broadened, from laboratory and clinical investigation to research on health services and implementation, quality improvement in health services, population health, community engagement and health equity.
This signal toward an increased interest in non-clinical careers is promising in the ways future physicians will, in addition to providing clinical care, be engaged in enhancing the health-care system. The trade-offs of balancing clinical and non-clinical roles, although challenging, must be tackled to address the impact on the volume of clinical care provided by physicians and the number of providers that may be needed to continue to meet current and growing future health care needs.
Table 1. AFMC* MD Student Entry Survey by Academic Health Sciences Centre (AHSC) and Distributed Medical Education (DME) Campuses 2019 to 2021
Question: “Please indicate your career intent from the different activities listed below (select all that apply) …”
| AHSC** | DME*** | ||||||
| Career Intent | 2019 | 2020 | 2021 | 2019 | 2020 | 2021 | |
| (n) | (144) | (317) | (774) | (39) | (94) | (240) | |
| % | % | % | % | % | % | ||
| Clinical Practice | 94 | 45 | 51 | 95 | 50 | 51 | |
| Research/Science | 2 | 19 | 19 | 3 | 21 | 15 | |
| Education | 1 | 26 | 22 | 0 | 21 | 27 | |
| Administration | 1 | 7 | 5 | 0 | 3 | 6 | |
| Don’t Know | 1 | 2 | 3 | 1 | 4 | 2 | |
| Total**** | 99 | 99 | 100 | 99 | 99 | 101 |
n= number of respondents
*Association of Faculties of Medicine of Canada
**Participating Academic Health Science Campuses (AHSC):
2019 and 2020: Dalhousie University (Halifax), Northern Ontario School of Medicine (Thunder Bay), Ottawa University (Ottawa), University of Saskatchewan (Saskatoon), Western University (London)
2021: McMaster University (Hamilton), Université de Montréal (Montreal), Northern Ontario School of Medicine (Thunder Bay), University of Ottawa (Ottawa), University of Saskatchewan (Saskatoon), Western University (London)
***Participating Distributed Medical Education (DME) Campuses:
2019 and 2020: Dalhousie University (Saint John), Northern Ontario School of Medicine (Sudbury), University of Saskatchewan (Regina and Prince Albert), Western University (Windsor)
2021: McMaster University (Niagara and Waterloo), Université de Montréal (Trois-Rivières), Northern Ontario School of Medicine (Sudbury), University of Saskatchewan (Regina and Prince Albert), Western University (Windsor)
**** Due to rounding, some columns do not add up to 100.
The comments section is closed.
August 10, 2023
Response to Comments from Dr. James A Dickinson
Healthy Debate Article: More research needed to understand medical students’ shift from exclusively clinical to scholarship
The authors appreciate Professor Dickinson’s thoughtful comments in response to our article highlighting a shift of medical student interest from purely clinical careers to careers also involving scholarly activity, education, and administration. We agree that the health human resources crisis is a topic at the forefront of many discussions about medical education and recent increases in provincially funded undergraduate and postgraduate positions in medical education are an attempt to increase the number of physicians who are being trained and will be the future of our physicians workforce (https://news.ontario.ca/en/release/1002882/province-helping-more-ontario-students-become-doctors-at-home-in-ontario).
It is important to recognize the data presented in the article from the Association of Faculties of Medicine of Canada represents the intentions of students early in their medical training and there will be many intervening factors along their training path that will influence the direction of their career. The survey results also did not allow for students to select multiple roles simultaneously. We know, from experience with faculty across many medical schools in the province, that many physicians are active in clinical practice while also holding positions of leadership or healthcare administration and engaging in education and research. Much of the work done to expose students to scholarly activity at our regional medical campus is to expose students to role models who are busy community clinicians while they also use scholarly activity and research to improve patient care and health service delivery within our community.
There is a common perception of “research” as an activity that is pursued outside of the realm of clinical work or education. The authors are encouraged by the broad definition of the role of scholar as defined by CanMEDS as “physicians [who] demonstrate a lifelong commitment to excellence in practice through continuous learning and by teaching others, evaluating evidence, and contributing to scholarship” (CanMEDS Role: Scholar (royalcollege.ca)). Such a broad definition that is fostered through undergraduate medical training creates physicians who are up to date in their practice, use current research and knowledge to inform their care and share their findings with their peers. It is through such physicians that we will find creative solutions to health human resource concerns and improve patient outcomes through better clinical care.
Many medical schools encourage and provide opportunities for students to engage in research activities. Participation in research can be beneficial for medical student by helping them develop skills in:
1. Broadening Knowledge
2. Critical Thinking
3. Scientific Literacy
4. Problem-Solving
5. Interdisciplinary Collaboration
6. Career Opportunities
7. Patient Care Improvement
8. Personal Growth and Time Management
It is important to note that while research can offer numerous benefits, medical students should strike a balance between their research commitments and their medical education. The demands of medical school are rigorous, and students should ensure that their research involvement does not negatively affect their academic performance or well-being. Medical students need to prioritize achieving their core curriculum objectives and attending to their own needs when they are also balancing scholarly projects during medical school.
The authors agree with the other possibilities Dr. Dickinson brings up that may influence student intentions for future practice. There is a very plausible selection bias that may occur whereby students who are already active in research were more likely to answer this question. There also remains the pressure of students seeking limited residency positions who may over emphasize the role of research in their future career paths. We must also interpret the findings carefully in recognizing an overall response rate of 20%, which may not represent the entire medical student population.
As authors we believe it is entirely possible to train students to serve community needs while encouraging them to consider a broad range of identities within their future practices. At our regional medical campus, we have a diversity of specialties chosen by our graduates, including many who choose generalist specialties, while also noting participation by 90+% of our students each year in scholarly activity. Many of our graduates remain in the community for their clinical practice or return following residency training and balance many concurrent roles in clinical work, education, and administration. The social accountability mandate to attend to the population’s health leaves room for physicians to also fill the needed roles of educator, leader, and scholar, most often while also remaining strong providers of clinical care.
Thank you for presenting this data. In a context where Canada is short of physicians, I find it very disturbing that the majority of entering medical students do not want careers primarily in clinical practice.
“It is often assumed that the primary goal of Canadian medical education, and the aspiration of those students, is to produce clinicians who provide care in a variety of medical disciplines.” I am sure that taxpayers and politicians who fund medical faculties make this assumption. I agree with the authors that scholarly activity is important, but this country does not need even 15 to 20% of graduates doing research. We need a few researchers, especially to assess how better to serve community needs. And all graduates should also be critical thinkers, able to distinguish what works and what does not, from the avalanche of ideas that will beset them throughout their careers. That is especially important for those who teach, which should be a high proportion of graduates. But that does not mean that medical faculties should change their focus even more towards research and education.
These authors suggest that new students are changing because of the pandemic and dissatisfaction with current clinical practice. But we should consider other possibilities. Perhaps medical schools are selecting students with greater interest in research than clinical practice. Or perhaps those answering the questionnaires are giving the answers they think the originators want. After all we know that when asked about their interest in high-income specialties, students and graduates say that is not an important factor, compared to the intellectual interest of the specialty. But their behavour tells a different story: the higher the income, the higher proportion of applicants to places available.
In medical school entry and training now, students know how difficult it is to differentiate themselves so they can obtain the opportunities they want. So they seek research opportunities, both before entry and during the course, working in someone’s lab in the hope of getting published papers that will polish their applications to improve their chances. This means they spend less time and effort learning the basics of medicine, which is already overwhelming. So they may be better in the narrow specialty they apply for, but are under-prepared for any other, especially for the many who miss out on their first choice and must take a lower preference.
Even during their specialty training, residents tell me that they must focus on research rather than improving their knowledge and doing good clinical care, to differentiate themselves in order to obtain the plum fellowships and career positions after they finish their training.
The authors are encouraged by this shift in stated career intentions, and consider encouraging interest in non-clinical research careers. Instead, I suggest they should be asking whether we are selecting the right students, giving the wrong messages during training, and encouraging diversion from learning the wide-ranging and complex biological, behavioural and social knowledge and skills needed to become a physician able to serve society’s needs. Without that, no wonder the students surveyed shy away from the complexity of real-world practice.
Yes, of course we need to change the dissatisfaction of the profession with current practice. So we need to improve the health care system, but that does not need we should stop training students to serve community needs. So yes, we need to research why and when students are turning in the wrong direction, and change both the explicit and “hidden curriculum” that influences entering students and trainees at every level away from clinical practice especially in the community and peripheral hospitals where they are so desperately needed.