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Shifting into third gear

Current options and controversies in third-year postgraduate family medicine programs in Canada

Paul Dhillon
Canadian Family Physician September 2013; 59 (9) e406-e412;

Abstract

Objective To summarize current options for postgraduate third-year programs in family medicine in Canada and compile current controversies about the expanding number of programs available and the trend toward subspecialization in family medicine.

Design A literature search was conducted by the Regina Qu’Appelle Health Region Library research staff for Canadian family medicine fellowships and residency programs using MEDLINE, PubMed, and the Cumulative Index to Nursing and Allied Health Literature from the beginning of 2005 to September 1, 2011. All available websites for programs offering third-year options were reviewed.

Setting Canadian family medicine residency programs.

Methods A list of current third-year residency programs was generated from the Canadian Post-MD Education Registry. In addition, the current Canadian Resident Matching Service website was reviewed, along with every program-specific website, for current third-year programs offered.

Main findings More than 30 different options for third-year residency programs are available, including a number of community-influenced and resident-directed enhanced-skills programs. In 2010 to 2011 there were 237 postgraduate third-year family medicine residents compared with 128 in 2010 to 2011, an increase of 109 positions.

Conclusion Controversies over the benefits to the patient population, the practice patterns of third-year residency graduates, and the influence of a subspecialty trend against a stated goal of comprehensive family medicine continue to exist, while the number of available third-year residency options continues to expand.

The increasing number of third-year family medicine postgraduate training programs across the country is a trend that is unlikely to abate in the near future.1 Since 1982, when the first third-year training program was recognized by the College of Family Physicians of Canada (CFPC) in emergency medicine (EM),2 there has been a strong growth in enrolment and a variety of positions available.

As of June 2012 the CFPC had approved the following 16 program areas under its Section of Family Physicians with Special Interests or Focused Practices (SIFP): addiction medicine, family practice anesthesia, child and adolescent health, chronic noncancer pain, developmental disabilities, EM, global health, health care of the elderly, hospital medicine, maternity and newborn care, mental health, occupational medicine, palliative care, prison health, respiratory medicine, and sport and exercise medicine.3,4 This increasing subspecialization of family medicine has been a topic of discussion and controversy for a number of years.2,4–9 For its purposes, the CFPC defines these 2 classes of physicians as follows.

Family physicians with special interests are those family doctors with traditional comprehensive continuing care family practices who act as personal physicians for their patients and whose practices include 1 or more areas of special interest as integrated parts of the broad-scope of services they provide.3

Family physicians with focused practices are those family doctors with a commitment to 1 or more specific clinical areas as main part-time or full-time components of their practices.3

The CFPC had numerous reasons for creating the SIFP initiative, including recruitment and retention of students in family medicine, as medical students and residents have reported that the possibility of developing several special interests throughout their practice careers4 is an incentive to practise family medicine. A stated objective of the SIFP initiative is to strengthen comprehensive continuing care, which has been interpreted as being paradoxical and is a point for further discussion and controversy. Before the CFPC’s 2008 approval of the SIFP, several of the programs currently under its remit were CFPC patient care committees.

In 1989 there were 66 third-year residency positions available to family medicine residents across Canada2; in 2011 there were 237 such positions that were filled and some that were left unfilled.1 Figure 1 illustrates this growth since 2001.1 There was a slight decrease in 2005 to 2007, but an exploration of the reasons for this is outside the scope of this paper. Overall expansion in the numbers of family medicine residency positions has also been seen, with 476 family medicine positions available in 2001 and 1257 available in 2011.10

Figure 1
Figure 1

Regular ministry-funded trainees in third-year family medicine training

Data from the Canadian Post-MD Education Registry.1

The number of more established programs in EM, anesthesia, and care of the elderly or palliative care continues to grow.11 This paper is the first to summarize the options that are available to family medicine residents for third-year training. In addition, it summarizes the current controversies that pertain to this expansion and the ability to formally have recognition of subspecialization training or focused practices within the realm of accredited third-year family medicine residencies.

METHODS

A literature search was conducted by the Regina Qu’Appelle Health Region Library research staff for Canadian family medicine fellowships and residency programs across MEDLINE, PubMed, and the Cumulative Index to Nursing and Allied Health Literature from the beginning of 2005 to September 1, 2011. A follow-up literature search of Canadian Family Physician was done in December 2011 for additional background information and to examine current opinions in the field. No summary of all the programs currently offered was found in print or online.

Canadian Post-MD Education Registry (CAPER) data were used to investigate the current options available. Unfortunately these data did not include detailed information about program-specific metrics. The Canadian Resident Matching Service website was reviewed for information about the CFPC EM third-year residency options available through the official third-year match process.12 The Canadian Resident Matching Service and CAPER data allowed for a list to be generated of all family medicine programs across the country. Each family medicine program website was then searched for a specific page with the current options available for third-year training, and information was taken from these webpages. Links to these webpages are listed in Table 1.

View this table:
Table 1

Links to third-year program information for each of the Canadian family medicine residency programs

FINDINGS

Table 21 illustrates the geographic spread of third-year family medicine residents across Canada, with EM being the only third-year option available at all 17 family medicine program sites. Other enhanced-skills options of some sort are available at 15 of the 17 sites. The specific types of program that are available are summarized in Table 3, which brings together all current options across the country for third-year training programs. The number of regular ministry-funded trainees matched to third-year positions is shown in Figure 1.1 Overall, there is an increasing number of ministry-funded trainees (with the exception of the previously mentioned 2-year period from 2005 to 2007).

View this table:
Table 2

Number of third-year residents (regular ministry-funded trainees only) by faculty of medicine providing the training in 2010 to 2011

View this table:
Table 3

Options for third-year residencies

DISCUSSION

As Table 3 illustrates, there is an increasing variety of programs available for third-year family medicine residents. This trend seems to have begun in the early 1980s when a crisis in emergency department staffing resulted in the staffing void being filled by family physicians. Consequently, a third-year training program in EM was created.2 To date there has not been any defining document describing the policy development, design, and implementation of the third-year family medicine program.2 Table 21 shows the spread of third-year programs across the country, with every residency program having at least 1 such program in EM available. The lack of data from CAPER about the exact breakdown of enhanced-skills programs does not allow for a more detailed geographic analysis of third-year residents.

Over the past decade the total number of residents enrolled in third-year residencies has been steadily increasing, with the exception of a short dip in the number of available positions in 2005 to 2006 and 2006 to 2007. Trends currently suggest that more and more family physicians have been narrowing their scope of practice or focusing their practices in certain areas.13,14 Among family doctors who do not specifically restrict their practices, about 80% have an area of special interest according to Dr Cal Gutkin, former Chief Executive Officer and Executive Director of the CFPC.14 Most of those who focus their practices do so in EM (25.8%) or geriatric medicine (9.1%).14

Issues raised in separate articles by Saucier5 and Green and colleagues,2 and in a recent series in the CMAJ,14–16 reflect on the controversies over the effect of this increase in “specialization” within family medicine. Such controversies are difficult to empirically test, and some might only be resolved with time.

Saucier5 found a number of positive perspectives in terms of third-year training, including, but not limited to, the following: rapid assimilation of specific medical knowledge; training of family physicians as continuing medical education experts for the larger family medicine community; creation of colleagues available for management advice on more complex cases5; and, in larger urban settings, becoming resources for providing care to specific communities. Negative aspects were also elucidated, including concerns about what message was being sent to “normal” graduates of the 2-year residency programs and issues around a “specialization” of family physicians when the current national needs assessments detail the need for generalists.

In 2009, Green et al published what is likely the most comprehensive research into perspectives on third-year residencies and the practice patterns of those graduating from 2- and 3-year programs.2 Many of the issues highlighted by Saucier in 2004 also arose in the results of Green and colleagues’ study. Succinctly, recognition that there was a need for family physicians with specialized skills in certain areas was given. However, there was trepidation that increasing the number of physicians pursuing third-year residency training would turn practitioners away from comprehensive family medicine.2 Other areas of concern were highlighted in the CMAJ series relating to patient understanding of physician credentials.16 Concerns have been raised about inadvertently misleading patients or providing a lower standard of care compared with Royal College specialties. In 2011, the College of Physicians and Surgeons of Ontario began to address this issue with rules that create a framework to ensure that qualifications and training are conveyed in a clear, accurate, and consistent manner.17

All third-year residency programs must follow the general standards governing family medicine program accreditation and the standards for residency training in enhanced skills for family practice.18 Currently, all third-year programs fall under 1 of 2 categories according to the CFPC. Category 1 options include EM, anesthesia, and care of the elderly, all of which have nationally accepted standards.18 In addition to these 3 options, which have specific sections or appendices in the CFPC Specific Standards for Family Medicine Residency Programs,18 the palliative care third-year residency is a dual program with the Royal College and would also be classified as a category 1 program. Category 2 programs address locally or personally defined curriculums within the university offering the program and do not have nationally accepted standards.18

Limitations

This was a single-author review of an area of rapid change in which new programs are created every year, and owing to the time from review to publication some programs might have been missed and more recent data from CAPER are not included.

Conclusion

The CFPC’s approval of 16 programs under the SIFP as of June 2012 has formalized a trend toward more recognition by the CFPC of the focused and special interests that many current or future family physicians have or aspire to obtain. There are now more than 30 distinct options for a third postgraduate year of training in family medicine and this paper collates the options currently available. A centralized digital database outlining all third-year residency options for applicants as they become available would be an excellent resource for applicants and for future research. The merits of the expansion of third-year training positions and the creation of the SIFP in terms of providing high-quality and effective comprehensive care are currently unknown, and controversies continue to exist across the country as to the downstream effects of this recognition.

Notes

EDITOR’S KEY POINTS

  • Third-year postgraduate programs in family medicine continue to increase in number and scope. The College of Family Physicians of Canada, under its Section of Family Physicians with Special Interests or Focused Practices, had approved 16 program areas as of June 2012. This study aimed to summarize current options for postgraduate third-year programs in family medicine in Canada and compile current controversies about the expanding number of programs available and the trend toward subspecialization in family medicine.

  • Currently there are more than 30 distinct options for a third postgraduate year of training in family medicine. Programs in emergency medicine are the most common, offered by all 17 family medicine residency programs. Other enhanced-skills options of some sort are available at 15 of the 17 sites.

POINTS DE RÈPERE DU RÉDACTEUR

  • Les programmes pour une troisième année de formation complémentaire continuent d’augmenter en nombre et en variété. Le Collège des médecins de famille du Canada, en vertu de sa section sur les médecins de famille possédant un intérêt particulier pour une pratique ciblée, avait déjà approuvé 16 domaines de programme en juin 2012. La présente étude voulait établir la liste des options actuelles pour des programmes de troisième année de formation complémentaire en médecine familiale et faire une compilation des controverses actuelles au sujet du nombre croissant de ces options et de la tendance à la surspécialisation en médecine familiale.

  • À l’heure actuelle, il existe plus de 30 options distinctes pour une troisième année de formation complémentaire en médecine familiale. Les programmes de médecine d’urgence sont les plus nombreux, étant offerts dans les 17 programmes de résidence. D’autres options visant l’amélioration de compétences particulières sont disponibles dans 15 des 17 sites.

Footnotes

  • This article has been peer reviewed.

  • Cet article a fait l’objet d’une révision par des pairs.

  • Competing interests

    None declared

References

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Shifting into third gear
Paul Dhillon
Canadian Family Physician Sep 2013, 59 (9) e406-e412;
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