Should family medicine residency be 3 years?

Changing times

Patients are living longer and many are developing multiple pathologies that interact with one another. Diagnostic and therapeutic possibilities have become more complex. While physicians in other specialties continue to focus on one area of specialization, family physicians assume primary responsibility for a growing number of pathologies. Their training must keep pace with these changes.

An ex-dean from Lyon, France, recently told me that many top students are choosing family medicine. In France, the training for family physicians is 3 years, which is the minimum in every industrialized nation except Canada.1

In 1964, when the first family medicine residency program was being established, there were many pioneers who wanted a 3-year residency. Last year, 24% of graduates of programs in Canada chose to take an additional year of training.

All residents should be offered a 3-year residency program. Upon completion of their training, they need to have mastered all of the skills inherent in the 4 principles of family medicine, as designated by the College of Family Physicians of Canada, which include the CANMED skills.

Pathologies are more numerous and more complex than they once were; there is a wider range of therapeutic options. Family physicians must now acquire new cross-disciplinary skills, such as management and cooperation, in addition to more traditional skills, such as scholarly learning, health promotion, and communication. Family physicians will soon be working in teams and will need to develop new interpersonal skills to weather this transition. They will need to be experts in teamwork and leadership, even when they are not patients’ primary caregivers. They will be called upon to see patients with complex or undifferentiated problems and patients who have failed to respond to treatment. They will need to maintain their skills at the leading edge of modern medicine. And that’s not all: in addition to maintaining the skills used in private practice, they will need to maintain expertise in the secondary care that is delivered in hospital and in emergency rooms.2

Our society’s needs are changing and becoming more complex. Here is a telling example: in the past, we rarely spoke of palliative care. Today, family physicians need to be experts in palliative care. A 3-year residency would promote the acquisition of cross-disciplinary skills and professional maturity. A 3-year residency would not eliminate the need for professional development—physicians must continue to learn, refine their skills, and keep abreast of new developments throughout their careers. Mentorship during the early years of practice is of invaluable assistance, but it does not eliminate the benefit of having mastered the skills during residency. New family physicians should be able to embark on complex practices with the minimum amount of stress and the maximum amount of confidence. In Arizona, the number of applications to a new 4-year residency program has increased.3

Some will say that we must produce hard data showing that extending (or shortening) a residency produces better physicians and lowers morbidity. Did we demand hard evidence 3 years ago when the Quebec College of Physicians extended the training for internal medicine and pediatrics by 1 year? In an editorial in the American Board of Family Practice journal, Winter4 reminds us that hard evidence is hard to come by. Two universities (Marshall and Tennessee5,6) ran a 2-year residency program as a pilot project. The residents did better on their examinations; however, these programs only admitted a small number of residents who were older and who had better-than-average academic records.

It is time Canada understood the challenge

It is a mistake to think of the current residency program as a 2-year program. The collective agreements governing residents in Quebec have improved; residents are now allowed more than 50 working days leave per year, exclusive of sick leave.7 The residency is barely 19 months long. When a resident is on call (every 4 days in Quebec), he or she is off the next day. This means that residents can be absent from their rotation settings for a total of 15 weeks in a year. The result? A residency of 1 year and 7 months, during which residents are only in their rotation setting for 13 months!

Thirteen months is not enough to train a physician in a specialty that, in my opinion, is one of the most complex and demanding there is! Other industrialized nations have understood the challenge. Canada’s family physicians also deserve a minimum of 3 years of training.