The College of Family Physicians of Canada (CFPC) is planning to increase the length of family medicine residency from two years to three.
The decision comes after consultations showing that two years isn’t adequate to expand the curriculum on increasingly important topics such as seniors’ care, new technologies, mental health and addictions, and the health effects of racism and colonialism – to name a few.
But some doctors, including some representatives of rural and emergency medicine organizations, want to see more consultation and evidence that the change is necessary.
They worry that lengthening training could worsen shortages in both family and emergency medicine (many emergency doctors pursue a family medicine residency followed by a one-year certificate in emergency medicine).
Of course, provincial governments will have to be willing to fund a three-year program. CMAJ reached out to several provincial ministries of health, but most did not respond, with Ontario citing the election.
According to Thomas Hunt of British Columbia’s Ministry of Health, “The proposed change requires further consultation with other provinces and faculties of medicine, which this ministry will be a part of.”
Three-year program a foregone conclusion?
In mid-May, the CFPC sent its members a document outlining terms of reference for an education reform taskforce whose “main deliverable” will be a “re-designed three-year core family medicine training.”
The taskforce will engage in this work over the next five years, meaning the first three-year family medicine program won’t launch until 2027, at the earliest.
Nancy Fowler, executive director of the CFPC, said the purpose of the taskforce is to determine how to phase in a three-year program without disrupting the supply of doctors – likely by rolling out the program in a staggered way at only some universities each year.
However, some are dismayed by what they see as a lack of consultation about whether the College should increase the length of training in the first place.
Sarah Giles, a family and emergency physician in Kenora, Ontario, said it feels like the three-year program is a “fait accompli.”
For instance, Giles said, when CFPC President Brady Bouchard presented the change to the Society of Rural Physicians of Canada conference in April, “it seems like the College is now trying to explain to everyone why they’ve made this decision and calling those discussions consultations.”
Giles and others are most concerned about the immediate impacts of delaying a cohort of family and emergency doctors from entering practice at a time when health human resources are already strained.
“Where I work, 33% of the emergency department shifts in the next six months are empty,” Giles said.
Sarah Lespérance, president of the Society of Rural Physicians of Canada, likewise cited “concerns about the potential health human resources implications in rural, remote, and Indigenous communities across Canada.”
Paul Dhillon, who practices rural and remote medicine in British Columbia, noted that increasing the length of residency may also make family medicine less attractive to trainees in the long run.
For example, combining a three-year family medicine residency with a certificate of added competency could end up taking as long as it would to train in a more lucrative specialty like internal medicine.
An extra year may especially put off trainees who hope to plan pregnancies around residency, Dhillon added. “We need to do a gender-based analysis.”
So Cdn #MedTwitter, when are we going to start talking about how this third year of residency proposed by the @FamPhysCan is a terrible idea? If rural FP grads can have a broad scope of practice after 2 years, why not change other programs to be similar? 🧵
— Dr. Sarah Giles (@SarahGiles10) June 4, 2022
A solution to recruitment woes?
When the CFPC launched its review of training in 2018, family medicine was already struggling to attract medical graduates to its ranks and seeing more practitioners narrow their practices on niche interests.
At the time, the College approached key groups, including the Society of Rural Physicians of Canada, to recruit hundreds of family physicians for consultations on what residency curriculum should include.
The consultations showed that family doctors wanted more focus on a range of areas based on the increasing complexity of health needs in Canada, changing technologies, and greater awareness of the health impacts of racism.
But according to Fowler, the College heard from residency programs that the curriculum was “already way too compressed” to expand on these topics.
When it comes to choosing a specialty, Fowler said she doesn’t think length of training matters as much as being able to “see a pathway to a really fulfilling career.”
“Right now, we’re worried that many can’t, and this education work is just a small piece of helping them,” she said.
Fowler noted that residents have told the College they would like more opportunities in different kinds of practices and settings.
“They say they would like to be able to choose which skills they need, whether that’s more emergency medicine, or more addictions and mental health,” she said. “There’s a lot of interest in being able to wrap the education around their career plans.”
Fowler stressed that training reforms can’t happen in isolation. The College is simultaneously pushing for other changes to attract doctors to the specialty, including changes in how family physicians are remunerated and the widespread move toward team-based, interdisciplinary care.
“Family doctors are not being supported to take on the increasing complexity of their work and, until those transformations can happen, nothing that we’ll be doing in education is going to be the definitive solution,” Fowler said. “Those kinds of efforts need to happen together.”
However, some take issue with the notion that doctors are abandoning cradle-to-grave family medicine because they don’t feel adequately trained for broad practice.
According to Dhillon, “There are so many other external factors and personal factors, such as job flexibility for doctors who have families, that are really driving what people do when they get into practice.”
Uncertainty for learners
Resident Doctors of Canada hasn’t responded yet to the College’s plan to increase the length of family medicine training. A representative told CMAJ they’re reviewing the plan and consulting members before issuing a position statement.
According to Aimee Kernick, chair of the rural and small urban section of the Canadian Association of Emergency Physicians (CAEP), “a lot of uncertainty” remains about how the reforms will affect learners, especially those pursuing family medicine as a pathway into emergency medicine.
“We want to ensure that the medical students’ and residents’ voices are really heard in this process,” Kernick said.
Facing a longer family medicine residency, some trainees may opt instead for a five-year emergency medicine specialty – in which case it would take even longer for those doctors to enter practice.
Kernick’s group is also worried about how increases in funding to support three-year family medicine residency might affect funding for other specialty training programs, including emergency medicine.
While the announcement of the three-year program took CAEP by surprise – “It’s always nice to hear about these things before and to be able to support the process,” Kernick said – the CFPC agreed last week to involve a CAEP committee in the planning over the next five years.
One possible upshot of the three-year family medicine program could be to reduce the length of a certificate of added competency in emergency medicine where those programs cover the same ground.
“Because we’re in crisis right now, it’s overwhelming to think of this change,” says Kernick. “But more time and more resources will produce higher quality care for our patients, if we use that time well.”
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