Electives are placement opportunities undertaken as part of the undergraduate medical curriculum and are necessary for applications to postgraduate residency programs. Across Canada, all undergraduate medical programs require learners to spend a certain amount of time on electives. The content and settings of electives are largely decided by the student undertaking them. Historically, learners have used this time to explore career options, improve clinical expertise, and engage in networking1 at sites that are and are not affiliated with their medical programs, described as home and away electives, respectively. Some residency programs also emphasize the need for applicants to have undertaken electives in the field to demonstrate their interest.
In 2019 the Association of Faculties of Medicine of Canada (AFMC) introduced the Student Elective Diversification Policy (SEDP), which set the maximum allowed elective time in a single entry-level discipline at 8 weeks.2 This policy was put in place to encourage learners to engage in a variety of disciplines in their elective time and to prepare them for potential career choices. With the SEDP, the AFMC is attempting to reduce the chance of medical graduates failing to match to residency programs through the Canadian Resident Matching Service (CaRMS) and encouraging learners to consider alternative disciplines and prepare accordingly.
Commentaries written about the SEDP by physicians involved in competitive Canadian postgraduate training programs have outlined substantial advantages to learners, such as encouraging the development of more well-rounded practitioners and increasing exposure to certain specialties.3-5 Thus far, however, we have not seen a publication explore the impact of the SEDP on applicants to family medicine. Therefore, we believe it is important to share our perspectives about this policy as family physicians and medical learners associated with undergraduate and postgraduate family medicine curricula at the University of Toronto (U of T) in Ontario. We believe the SEDP may reflect inadequate family medicine representation at the AFMC or at least an inadequate understanding of family medicine practice realities and education needs. This is an important perspective to share, as we view the SEDP to be an unnecessary obstacle for learners attempting to explore the breadth of family medicine, a specialty that represented 46% of all first-year residency spots in 2022.6 We are concerned this policy could contribute to a reduction in interest among medical learners and consequently lead to a diminished family physician work force. During a time of crisis in family medicine, this policy feels like another nail in the coffin.
Since the SEDP was introduced in 2019, we have heard from many undergraduate medical learners about how the SEDP has negatively affected their ability to truly explore family medicine. This is primarily because the SEDP counts all family medicine electives as equal. Therefore, whether a learner spends elective time with a family physician providing comprehensive care in an urban or suburban setting, practising family medicine in a rural setting, or working with a family physician in an enhanced skills (ES) focused practice, the SEDP counts these experiences under the same 8-week cap dedicated to family medicine. This decision stems from the fact that the AFMC sees ES programs as requiring a secondary match following 2 years of residency training, and they therefore should count toward the elective cap of the primary direct-entry program. This type of approach is not appropriate for family medicine for 3 distinct reasons.
Comprehensive and ES family practices are quite different
Differences may include contrasting scopes of practice, locations, populations served, and compensation methods. Exposure to these potentially different clinical experiences, teachers, and mentors, from both comprehensive and ES practices, are important for student career exploration. Moreover, these elective experiences in undergraduate medical training are essential to career planning for residents, as family medicine residents must decide relatively quickly and with little elective opportunity in their first year of residency whether they are interested in applying to ES programs. Given that the application process for ES programs begins at the start of their second year, there is a very small window for residents to decide whether having ES training could be relevant to their future practices and if it would benefit the communities they wish to serve. It is important to note that in other specialties such as internal medicine and pediatrics, learners have separate elective caps for general practice and for the various subspecialties, such as cardiology or endocrinology. As a group, we wonder why this dissimilar approach exists in programs that parallel family medicine.
Direct-entry ES training programs exist
Enhanced skills training programs have evolved over the past decade and continue to be a hot topic of conversation in academic circles. Most recently, one such integrated program was created at Dalhousie University in Halifax, NS. The integrated family medicine–emergency medicine program lets learners commit to ES programs directly from the CaRMS match, which contradicts the view of the AFMC that ES training is for secondary matches.
Rural family medicine differs from urban and suburban family medicine
Often, family physicians in rural areas provide a broader scope of care and work in a wider array of settings. Moreover, family medicine is the only specialty in which learners can apply directly to rural streams, a learning opportunity that is quite different from training in academic centres. One could argue that by limiting medical students’ opportunities to experience the discipline in these disparate settings, they will be ill equipped to apply to any of these programs.
To understand the impact of this policy, we reviewed local data and tried to detect any trends in interest in family medicine among undergraduate medical elective learners. The Department of Family and Community Medicine at U of T offers a diverse array of electives, including experiences with family physicians practising comprehensive care in the greater Toronto area, practising comprehensive care through the Rural Ontario Medical Program, and practising in focused practices, such as those in addiction medicine, palliative care, or emergency medicine. Data provided by the U of T MD Program’s electives office indicate that overall interest in family medicine electives has been increasing. Over the past 4 years, medical students at U of T have collectively spent, on average, 600 to 700 weeks per year working with family physicians during electives. Students spent about half of this time at comprehensive practices and half at focused practices. As the availability of Rural Ontario Medical Program electives is limited, and their length is predetermined at 4 weeks, only about 20 learners participate in this elective experience annually.
Despite these encouraging numbers that may indicate a potential surge in interest, CaRMS data suggest interest in family medicine is actually decreasing. In 2021 a total of 207 family medicine spots went unfilled in the first iteration of the match.7 This disappointing result seems to have been echoed in the 2022 CaRMS match, with first iteration results revealing 225 family medicine spots across Canada went unfilled, representing 72% of all unfilled residency spots.6 Also, despite a substantial increase in the number of applicants to family medicine programs over the past few years, peaking at about 2000 Canadian medical graduates, the number of applicants who rank family medicine as their first choice has decreased.6 Our group believes this is more than likely due to an increase in applicants backing up other program choices with a career in family medicine as their second or third choices to avoid going unmatched.
Conclusion
The AFMC has made an excellent first step in ensuring medical students have equitable and diverse learning experiences for electives. While the elective process during the COVID-19 pandemic has changed (ie, with the restriction of away electives), and data about the implementation of the SEDP have yet to be released, we are certain the SEDP will have a positive impact on learners applying to many specialties. We also welcome the idea that learners interested in family medicine are encouraged to be exposed to other specialties that support the development of clinical skills in areas that will contribute to the practice of comprehensive family medicine in the future. Yet, we are worried that this policy will affect learner interest, match rates, and, eventually, work force availability and job satisfaction among family physicians.
It is well known that Canada is suffering from a family physician shortage. Therefore, it is clear that at a time when academic family medicine is undergoing many changes—including the introduction of the Family Medicine Professional Choices test as a mandatory requirement for the application process to 13 postgraduate family medicine programs in Canada8 and the transition to a 3-year family medicine training program—we should focus on incentivizing learners rather than creating obstacles. We are concerned that the SEDP in its current form will lead to a decrease in learner interest in family medicine.
Based on our roles as educators and clinicians, we argue that to train competent and satisfied family physicians, it is necessary to let learners truly experience the breadth of our discipline, without being limited by a cap. We strongly recommend that the AFMC view family medicine similarly to internal medicine and pediatrics, where subspecialties are counted toward an elective time cap separate from that of comprehensive practice. This would allow learners greater opportunities to explore the breadth of family medicine and appreciate family physicians as highly skilled medical experts, advocates, collaborators, leaders, teachers, and scholars capable of adapting to the needs of their patients and communities across a multitude of settings and clinical environments.
Footnotes
Competing interests
None declared
The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.
This article has been peer reviewed.
Cet article se trouve aussi en français à la page 17.
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