Extended family medicine training

DISCUSSION

The results of this study clearly demonstrate an increase in the number and proportion of family medicine trainees who undertake extended training (Table 1). While this study reports changes in the actual numbers of trainees exiting extended family medicine training programs, future research could reveal more about a possible unmet demand for extended family medicine training. For example, Canadian Resident Matching Service data suggest there might be an unmet demand for training in emergency medicine. Every year since 2007 there have been more applicants to emergency medicine programs than positions offered and most of the positions are filled each year.¹¹

Extended family medicine training might be integrated into practice in a variety of ways. For example, it might support rural family practice, which is reportedly broader in scope.^12–18 Family medicine residents who plan to provide comprehensive care in rural communities might use extended training programs to prepare for the provision of surgical, obstetric, hospital-based, indigenous, and other types of care that are generally more characteristic of rural family practice. Other research suggests that rural family doctors might restrict their practices to specific areas, such as anesthesia care,^18–20 which might be enabled by extended training. Moreover, there is evidence to suggest that some family physicians might practise exclusively in emergency departments, sports medicine clinics, or tertiary care hospitals.^13,21,22 Family physicians might be motivated to take extended training for a variety of reasons. Some might be preparing for the broad health care needs of the geographic community they plan to serve. Others might be more focused on the demands of a particular type of clinical setting or health condition.

If there is uncertainty about how extended family medicine training influences future practice scope, there is no question about its variable uptake across faculties of medicine (Table 3). For example, approximately one-quarter of family medicine trainees at the Northern Ontario School of Medicine pursue extended training compared with slightly more than one-tenth of those at the University of Montreal. Many factors might contribute to cross-faculty variability in the proportion of family medicine trainees who pursue extended training. It might, in part, be linked to variations in provincial government funding for extended family medicine training. Cross-faculty variations in extended training might signal the particular emphasis faculties of medicine place on preparing family physicians for future practice in rural communities. More generally, extended training variations might reflect the unique pedagogic cultures and educational approaches of Canada’s faculties of medicine. In an effort to better understand variations in extended training uptake, future research might contrast the learning environments within family medicine departments that produce relatively more and relatively fewer extended training family physicians.

As shown in Table 4, there is a multiplicity of extended training programs that cut across a range of clinical areas. Some extended programs focus on specific procedural skills or health conditions that might be seen as peripheral to family medicine (eg, surgical skills, hospital medicine, occupational medicine). Other extended training areas, such as chronic disease, mental health, and care of the elderly, might be seen as the stock-in-trade of family practice. For each extended training area, family medicine educators might debate what learning is essential within the first 2 years of family medicine training and what additional learning might be more appropriately covered in extended training programs. Certainly, it will be interesting to monitor how new initiatives, like the Triple C curriculum and CACs, affect the number and breadth of as well as enrolment in extended family medicine training programs.

The current study shows that CMGs are almost twice as likely to pursue extended family medicine training as IMGs are (Table 2). Demographic statistics indicate that IMGs are, on average, considerably older than their CMG peers at the time of entering postgraduate training.^23,24 As a result, IMGs might be inclined to complete their residency training as quickly as possible to move on to fully licensed medical practice. At the same time, IMGs might be constrained by return-of-service agreements that preclude or limit their ability to pursue extended family medicine training. If IMGs are less likely to establish long-term practice in rural communities, as some research suggests,^20,25–27 then they might believe they are less in need of extended family medicine training. While the cause of IMG-CMG training differences might be complex, further study could improve our understanding of potential barriers to IMG participation in extended family medicine training programs.

Past research examines downstream family medicine practice, but much could be learned from studies that retrospectively or prospectively explore the relationship between extended family medicine training and scope of future medical practice. Extended and specialized training might prepare family physicians to practise within a narrower scope of health care delivery. Conversely, extended training might augment the otherwise comprehensive practice of family physicians. For example, extended emergency medicine training might prepare family physicians to work exclusively in emergency departments or it might instill an “add-on” skill set, to be used by the family physician while away from her or his regular, broad-scope family practice clinic. Certainly, residency training is unique for each family physician; it takes place over a particular time period and in the context of a defined population. The study data presented here underscore the need for further research to understand how extended family medicine training shapes future medical practice and, ultimately, the role of family physicians in providing health care services to Canadians.