For some years, universities and other organizations have questioned the length of specific training in family medicine, which is currently 2 years. Four years ago, the Collège des médecins du Québec asked the Fédération des médecins omnipraticiens du Québec to weigh in on this subject. At the time, we said that the 2-year residency was long enough and, based on the considerations I discuss below, we still think that it is sufficient.
There is no indication from the pass rate on the end-of-residency examination that there are gaps in the knowledge and skills of residents completing their 2-year training. The reason most often given for extending the family medicine residency is that residents do not feel confident in their knowledge of the range of subjects that their profession, by its nature a multifaceted one, will require of them. At first glance, increasing the length of their training might seem like the right response to the need for an increasingly broad knowledge base. However, the various efforts that have been made in this direction actually lend support to the view that extending their training is not the answer.
Loss of a more typical multifaceted practice
Let us consider the example of the third-year programs currently offered in Quebec and in Canada that culminate in a certificate in emergency medicine, palliative care, or geriatrics. More often than not, the net result of this approach is a targeted—even an exclusive—practice in one of these fields, at the expense of a more typical multifaceted family medicine practice. Unfortunately, the pursuit of this approach further exacerbates the shortage of family medicine “generalists.” Graduates adopt a narrower scope of practice from the beginning instead of narrowing their focus gradually over time, as happens with most family physicians.
Sweden has often provided prototypes for practices that are adopted in other countries because of its innovative approach. In introducing a 3-year family medicine residency, associated with a 5-year tutorship leading to certification, Sweden extended its family medicine training considerably. There can be no doubt that the residents acquire more knowledge in this program, which, in length, comes close to our longest residencies (ie, 6 years in cardiology, cardiovascular surgery, thoracic surgery, and neurosurgery). Extending the training in this way, however, would lead to a 1- to 3-year halt in the production of new family physicians. The immediate result would be a substantial drop in the availability of family physicians who are already in short supply. Recall that, last year, their ranks grew by a mere 61 family physicians in Quebec.
According to the largest Canadian study ever of family medicine, conducted by Dr Marie-Dominique Beaulieu, the Dr Sadok Besrour Family Medicine Research Chair at the University of Montreal, these “super residents” would reinforce the model of an “omniscient” physician—a model that young residents and students in medicine find unrealistic, if not terrifying.1 For them, the generalist does not approach his or her work by taking on every single medical problem; he or she “manages any problem that comes up,” which might involve referral to another health specialist. In this manner, family physicians “orchestrate the various forms of care that are being delivered in an increasingly complex health care system.”1
Many ways to support and reassure new family physicians
The insecurity that new family physicians quite naturally feel in response to the range of skills that their profession demands of them can be addressed through a variety of measures. I have divided these measures into 3 groups: organizational skills, access to support on an as-needed basis, and adapted, ongoing professional development. A group practice is a great source of support, providing opportunities to discuss cases formally and informally and opportunities for mentoring, as is now the case in obstetrics. Access to the diagnostic and therapeutic resources of the health care system, the ability to search for information electronically, and rapid access to the advice of experts thanks to an interdisciplinary working environment represent other ways to support and reassure family physicians. A system in which each general practitioner manages his or her own professional development is another supportive measure, particularly if ongoing professional development can be accessed without financial penalty and at a reasonable cost, if it involves practice support tools that are readily available, and if it addresses needs experienced by individuals, groups, and the interdisciplinary team as a whole.
Last, let’s look for a moment at the experience in France, where extending the training for front-line medicine has led to a specialization in practice in various fields, notably hospital care. This process has exacerbated the shortage of front-line medical resources, adding to the image of front-line care as the “poor cousin” of the health care system.
In Quebec, the percentage of family physicians who are active in second- and third-line care is already quite high: 39%. Our French counterparts were limited to front-line care and were not allowed to acquire the status of “hospitalists.” Now that they are allowed to deliver hospital care, the shortage of staff on the front line continues to worsen. This is a pattern we see in Quebec with new family physicians who have completed extended training in a specific, narrower field.
CLOSING ARGUMENT
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Unless we can identify some need to correct a situation that is alarming or disturbing now or later, the current length of the specific training in family medicine is adequate and sufficient.
Footnotes
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Cet article se trouve aussi en français à la page 347.
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Competing interests
None declared
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