Pursuing longer family medicine residency training

Dear Colleagues,

Debates about how long family medicine residency training should be are not new or unique. Concerns were raised more than 20 years ago by Quebec family medicine residency programs about decreased clinical experience (eg, work arrangements post call, education, and duties in important but nonclinical areas). The American Board of Family Medicine recently held a summit on the future of family medicine, during which this question was considered. New family doctors have shown that they are able to make important contributions to community-based care, including in resource-constrained environments. Why should we revisit this now?

We needed to reflect on a few critical situations. These include the discovery that there was more variability in training experiences in certain areas, such as emergency care, across residency programs than we had anticipated. We learned that when the Triple C Competency-based Curriculum¹ was introduced 10 years ago, there was an insufficient understanding of how comprehensive care was being defined and, specifically, what graduates were expected to be able to do across the broad scope of family medicine. There is evidence for a declining scope of practice, the causes of which are undoubtedly complex, but there are concerning potential ripple effects for physician well-being, patient access, and health system function.

In 2018, the CFPC released the Family Medicine Professional Profile.² It reaffirms our collective commitment to high-quality, comprehensive care close to home for the people of Canada—a comprehensive basket of services, throughout the life cycle, in various clinical settings. Through the Outcomes of Training project, we have more clearly defined what we are aiming for with family medicine residency training. Through an extensive review of the literature, field research with family physicians, a robust process of consultations, and the use of key sources of data (including the Canadian Post-M.D. Education Registry, the Canadian Medical Protective Association, and results from the Family Medicine Longitudinal Survey), we have defined the core professional activities of family physicians and created a Residency Training Profile for family medicine, and for the enhanced skills training that lead to a Certificate of Added Competence. The Residency Training Profile establishes expectations for more robust educational experiences in a number of clinical and nonclinical areas, including home and long-term care, treatment of substance use disorders, chronic illness care, care of those with complex comorbidities, acute care, virtual care, practice improvement, and leadership. We need to pay dedicated attention to dismantling systemic racism and enhancing culturally safe care for Indigenous peoples, along with other diverse and racialized groups. We have the shortest residency training program in the world, and our family medicine residency program directors tell us that “the curriculum is full.” They also tell us that if residency is lengthened, it cannot be “just more of the same.” We want to better support the transition to practice, to address new competencies, and to achieve the variety of experiences that build adaptability and preparedness for practice. We are actively thinking about what this should look like, in collaboration with family medicine educators.

Although some decision makers prefer to think of community needs as primary, secondary, or tertiary care, we prefer to position our contribution in terms of proximity care. We commit to a person and to meeting their needs wherever they are, using all means available to us, including collaboration, continuity, and innovative technologies.

Through the Outcomes of Training project, we are reaffirming the need for training that equips family doctors to be leaders in primary care; we also need to prepare them for a scope of practice that is exceptionally broad, beyond traditional limits of what is considered primary care. Ongoing educational renewal is a necessary but insufficient ingredient to an improved delivery of community-based care. It must be accompanied by policies and remuneration models that support comprehensiveness and continuity rather than incentivized episodic care. A big task at hand, but the time has come. The status quo is no longer an option for us.

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