I very much enjoyed Dr Noel’s thoughtful, balanced commentary, which ultimately advocates a 3-year residency program.1
He does a very good job of canvassing the contrary position. I found his “Parkinson’s law” concern compelling—the risk that “the same material covered in a 2-year curriculum”1 might simply be spread over a longer period. The capacity challenges posed by any attempt to extend the duration of the program during this period of massive expansion of undergraduate enrolment make this inevitable in my view. As things currently stand, second-year residents (in British Columbia at least) are increasingly challenged to secure meaningful electives, such is the competition from the growing ranks of clinical clerks and specialty residents.
Then there are the twin pragmatic obstacles: governments have no money at present and, even allowing for the fact that “it would only be for 1 year,”1 a graduate hiatus in the current climate of perceived provider shortages is politically intolerable. Asking provinces to endorse a third year in this context is asking the impossible.
So, in the short-term at least, a 3-year program seems unlikely.
Fortunately, there is a workable alternative—even more aggressive promotion of group practice models. Even with the substantial improvements brought on by primary care reform initiatives, the work environment in our discipline (and most others) remains incompatible with the life aspirations of large numbers of new graduates, particularly young women with children. Recruitment to practice increasingly depends on accommodating young people. Business management responsibilities must be covered and specified hours of work guaranteed. More creatively, mentoring by more experienced colleagues needs to be part of the package.
Dr Noel appropriately concludes with a reference to “lessons of the past.” The slightly more distant past also holds some useful examples of what can be done to help inexperienced, younger colleagues. Many of our most respected older family medicine teachers came of age when postgraduate training included little or no formal curriculum—usually a rotating internship, followed by, for example, 6 months each of anesthesia and obstetrics. In clinical education parlance, “all service and no teaching.” Those doctors made the transition to “master clinician” competencies by joining supportive medical communities, often, but not always, based in clinic groups or small-town hospitals. Every working day began with an opportunity, over coffee in the medical staff lounge, to discuss cases with more experienced colleagues.
No one is advocating reverting back to laissez-faire learning. But it is a sad reality of the past 2 decades that family medicine has become more fragmented, despite explicit efforts to model team-based service provision in training. Communities of family physicians are working hard in many places to address that. The fruits of their efforts have the potential to re-create the on-the-job learning opportunities of the past, without the inhumane hours and expectations that are simply no longer acceptable.
While it is obviously true that 2-year trainees are not “master clinicians,” I question whether a third training year is the best way to solve that. Early practice experience in well-functioning groups has the potential to consolidate and build on one’s foundation of clinical skills, while, not incidentally, being paid as a real doctor.
I do acknowledge the “hunger” for third-year programs that Dr Noel cites. It is not new. My concern, however, is the extent to which so many of these programs lead new graduates away from generalist practice at a time in their professional lives when they need it as a key component of their professional formation and confidence. I would suggest mandating a minimum of 5 years of community general practice as a prerequisite for primary care subspecialty training (sports medicine, emergency medicine, palliative care, geriatrics, addictions, GP oncology, etc)—but that is another matter entirely!
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