A look back to see ahead

Medical education

From the beginning, the SOR Council has had an interest in both undergraduate and postgraduate medical training. In 2003, the Canadian Residency Matching Service reported an all-time low of only 24.8% of medical school graduates choosing careers in family medicine.4 Given that millions of Canadians were unable to find family doctors, this low level of interest was of great concern. For this reason, family medicine interest groups were strengthened throughout the medical schools. The SOR Council supported this endeavour and encouraged all family medicine residents to greater involvement with undergraduate medical education. In the past 2 years, the Residents As Teachers program further strengthened that commitment to medical education. In the most recent 2010 match, 31.8% of graduates chose family medicine as a career.4 Although the increasing interest is encouraging, the SOR continues to promote family medicine as a career choice to medical students.

Naturally, postgraduate training in family medicine has been of particular interest to the SOR Council. Since its inception, documents known as Marchpasts have been presented and discussed at the twice yearly meetings. Marchpasts are documents prepared by representatives from each family medicine residency program detailing the components of the training, including strengths and weaknesses. Through our discussions, we share suggestions on how to improve the respective residency programs.

In 2003, a document, which would eventually be called the Guidelines in Family Medicine Training: Curriculum Resource for Residents and Program Directors, was developed by the education subcommittee.5 This document presents a detailed look at how each training component of family medicine is organized in various residency programs. Both strengths and weakness are explored. Moving forward, this document will continually be updated and will be important when residency programs consider curriculum review.

Distributed education

In the late 1980s and early 1990s, family medicine programs expanded geographically and away from traditional university teaching centres. The issue of distributed education is once again a hot topic of discussion, and many of the concerns discussed in 1989 are mirrored by those of 2009 and 2010. Residents today seek to achieve a sense of connectedness with their colleagues through e-mail newsletters, annual program-wide retreats, and teleconference academic half-days. New family medicine training sites seek to offer equivalent training experiences to those of established academic centres, while not losing the unique strengths and experiences smaller communities can offer.

There was, however, a time when downsizing, and not expansion, was foremost in residents’ minds. In February of 1992, the first portion of the Barer-Stoddart report was published in the Canadian Medical Association Journal, with a final total of 12 papers published between 1992 and 1993.6,7 Of all the recommendations within that report, the recommendation to cut medical school enrolment by 10%—and the subsequent actions of provincial ministers of health—was a concern not only for residents, but for all medical professionals. At its March 1992 meeting, the SOR Council composed the following resolution: “[The SOR] supports the position of the CFPC that the eventual reduction in medical school enrolment by 10% as an effective attempt to reduce health care costs in Canada would be drastic and ill-conceived.”8 Though the direct effects of the Barer-Stoddart report are still arguable,7 the shortage of family physicians9 created a sense of urgency in family medicine training.

Continuity of care

Continuity of care is a central principle of family medicine, playing an important role in the development of the physician-patient relationship. Continuity is widely regarded as beneficial for patient care, judicious use of health care resources, chronic disease management, and both physician and patient satisfaction.10

One area in which the experience of continuity of care can be particularly elusive for residents is family medicine obstetrics. To capture the experience of seeing a woman for her prenatal counseling, antenatal care, delivery, and well-baby visits can be a challenge for a resident who might be working in several different clinics, hospitals, or cities over the course of a patient’s pregnancy. Family medicine residents’ experiences with obstetrics vary widely among programs and across the country. Nearly every year, in the Marchpast presentations, obstetrics rotations are raised as an issue by at least one program representative, with concerns generally centred on integration with the specialist team and ability to achieve the target of at least 3 to 6 family medicine deliveries.

In 1992, a representative to the SOR Council from the Canadian Association of Interns and Residents, reported that a Taskforce on Obstetrics and Neonatology had been formed. Of particular importance to family medicine residents, it was thought that there should be more family medicine role models practising obstetrics and that neonatal resuscitation training should be offered to all residents. Since that meeting, the number of family physicians practising obstetrics has only continued to decline. From 1989–1990 to 1999–2000, the proportion providing this care in Canada declined from 28% to 13% among established physicians and from 27% to 15% among recent graduates.11 Although obstetrics care continues to be promoted by programs and preceptor role models, this is one area of continuous care that remains a challenge for residents.

Focused practice

Although it might be natural for all physicians to have special areas of interest, the drive for family physicians to subspecialize is perhaps greater and different than for other specialists. The motivation might be based on remuneration or prestige. Some have argued that the move toward specialization is fueled in part by the physician shortage.12 Physicians who are otherwise interested in comprehensive practice are forced to focus their practices in order to maintain personal work-life balance.

Family physicians who pursue emergency medicine make up the majority of focused-practice physicians. The emergency medicine program is arguably the most well-organized special interest program within family medicine. Since 1982, a special designation has been bestowed upon those successfully completing the special competency examination in emergency medicine.13 In the latest National Physician Survey, 72% of physicians registered in the emergency medicine program wished to pursue careers exclusively in emergency medicine.14 This has been a point of detailed discussion at SOR Council meetings.

There has been ongoing discussion of whether the family physician shortage is further exacerbated by the career choices and focused practices of some family physicians. Given that the main focus of family medicine is continuity of care, does a focused-practice physician shift this long-standing goal and mantra? From a postgraduate education perspective, has there been enough linkage with family medicine during the third year of training?

In light of the changing landscape of family medicine and its training programs, discussion of these issues is ongoing and ever evolving. Recently, there has been a strong effort to communicate with third-year family medicine residents to gain insight into their experiences and expectations with respect to enhanced skills training and linkages with traditional family medicine.

In 2009, a new section, the Section of Family Physicians with Special Interests or Focused Practices, was formed within the CFPC. This section will include representation from various focused-practice groups, such as emergency medicine and anesthesia. Going forward, the SOR Council will work hard with this new section to promote the interests of residents and their future career and practice choices.

Examination costs

Examination costs have been an issue of considerable discussion within the SOR Council. The average graduating medical student has accumulated more than $100 000 in debt.15 Many medical graduates have family dependants to support in addition to other financial resource demands.

Further, many residents have to travel from rural training sites to sit the examinations, which are only offered in selected cities. Residents who prefer to write the Certification in Family Medicine examination in French must travel to Quebec. Given the short length of the family medicine residency program, the expenses detailed in Table 1 are substantial.16,17 In as early as 1990, the SOR Council advocated for and was granted a seat on the Examination Committee (the CFPC committee responsible for setting examination policies). The issue of cost is as important today as it was then. Despite, however, our best efforts to keep costs to a minimum, the continual development, administration, and evaluation of the examinations require substantial financial resources.

Currently, there is a plan to harmonize the Medical Council of Canada Qualifying Examination Part II with the CFPC’s Certification in Family Medicine examination and to open more examination centres. In the long term, this should help to decrease the cost of examinations and reduce travel time and costs for residents. The SOR is represented at all levels of these discussions. It is our hope that these solutions will eventually result in a substantial decrease in examination cost to residents.

Conclusion

In looking back on the SOR Council’s 20 years of existence, it is clear that this group can play a crucial role in continuing to inform and even educate the rest of the College about the ongoing challenges involved in learning the skills of family medicine. Through their representatives, every resident group across the country has a direct voice in the decision-making processes that guide their training and Certification. Even in the age of Internet, e-mail, video conferencing, and Facebook, communication among distributed sites can be a challenge. Continuity and comprehensiveness of care will always be our ideal, but specialized interests and declining participation in obstetrics and hospitalist care will weigh on the balance. On the whole, however, learning more about the work of the CFPC and the SOR Council—seeing the hard work done through the years to enhance the resident experience and thereby enrich future practice—has been an inspiration. We have looked back to see ahead, and we see our current leaders who have borne us forward and our future leaders ready to take on the charge.