Beyond primary care: update on the Outcomes of Training project

Dear colleagues,

We are releasing the report and recommendations of the Outcomes of Training project this month. It follows an extensive literature review, examination of various data sources, and consultations with members, educators, medical students, and residents. It builds on the 2018 Family Medicine Professional Profile,¹ which describes our collective commitment to service to Canadians, and the 2021 Residency Training Profile,² describing the core professional activities for which residents are being prepared.

To be clear: We are producing competent family physicians. At the same time, we hear that family doctors today are practising less comprehensively. Some lack interest and never intended to include certain family medicine domains (eg, intrapartum care, long-term care) in their practices even before entering residency. Many want to practise comprehensively but find themselves unable to, owing to health systems that do not support them. Residents, although competent, might not consistently have the depth and breadth of education and service experiences to feel confident practising in certain clinical areas. Personal factors are also at play. Additionally, the role of family physicians is shifting with an aging population and dynamic social and health care changes, which results in caring for patients with more complex needs in the community.

Looking forward, we want to provide opportunities for skill consolidation in areas such as acute care (emergency, in-hospital), long-term and home care, procedures, and emerging areas like virtual encounters, cultural humility and safety, Indigenous health, informatics, and panel management. Program directors indicate the curriculum is full. To enable comprehensiveness and curriculum enhancement we are recommending moving to a 3-year residency, bearing in mind we currently have the shortest postgraduate family medicine residency in the world.

We are aiming to produce family doctors with broad scopes of practice and the confidence and ability to adapt to evolving community needs. There is limited evidence from the United States that residency programs that extended the length of training produce graduates who practise more comprehensively, and that interest in those programs from medical school graduates remains high.³

Education reform is only one key ingredient in improving access to comprehensive care. It must be accompanied by transformation in health system organization to support family doctors in doing their best work, grounded by their communities’ needs. These must evolve in tandem and be integrated. Residents must have opportunities to learn and serve in team-based models staffed adequately to ensure continuity, after-hours care, and access to comprehensive services. The Patient’s Medical Home provides such a vision.

Next steps include creating a business case for extended training, as we believe front-end investment to support comprehensiveness will strengthen the health system and lower costs; convening an education task force to assist with curriculum design principles and the change process; consulting an advisory group about advocacy needed at the health system level; and planning regular conversations with Chapters, faculties of medicine, and provincial and territorial decision makers to better understand their realities and to plan our way forward regionally. Changes to the accreditation of residency programs and to the Certification process will evolve but not come into effect for 5 years. Our intent is to phase in the implementation and have some graduates of the new 3-year residency programs by 2030.

New family doctors want to do good work but tell us they need work-life balance; they see themselves in group practices, paid through alternative payment plans, so they can provide high-quality care and respond to community need. We need to present a mode of practice they will want to take on—a sightline to a sustainable and meaningful career.

A report from the University of Toronto⁴ reminds me, through powerful stories shared by family physicians, that we do so much more than primary care: we go where we are needed (long-term care, patients’ homes), when we are needed, and are there for our patients no matter the problem. The pandemic has changed us all. In some instances, it has made us more aware of disparities. There are important lessons to be learned. Let us enhance the training of future family physicians and the milieu in which they learn and work to best prepare them for the care Canadians will need.

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