Consult the members

Further to Dr Loh’s column in the January issue of Canadian Family Physician,¹ I am concerned the College of Family Physicians of Canada’s (CFPC’s) plan to extend family medicine residency to 3 years will harm the specialty.

Family medicine is increasingly being done by nurse practitioners and physician assistants, both groups who have magnitudes of order less training than family doctors. And now we can add pharmacists to the list, who do not get any formal training on differential diagnoses. These groups have done an excellent job advocating for themselves vis-à-vis that less training is not a problem and, in response, many patients feel comfortable receiving primary care from them. This is in spite of the fact that data from other jurisdictions show that nonphysician providers cost the system more in the long run.²

Family medicine already has a public relations problem. The hidden curriculum at medical school is that family medicine is the lowest-status specialty and one of the lowest paid. Adding in an extra year of training, when evidence shows that patients who have a family doctor have a mortality benefit, and at a time when the role of family doctors is being eroded through government-sanctioned increases in the number of nonphysician providers, seems detrimental to the future of family medicine in Canada.

The justifications raised in Dr Loh’s article do not explain how on the one hand it is safe for nonphysicians to have expanded, independent medical scopes, but on the other hand physicians need more training to occupy the same jobs. Before such a drastic, far-reaching change, would it not be prudent to ask the dues-paying members of the CFPC? There should be a referendum on this issue.

Moreover, the 2-year residency is by no means “packed.” I say this as someone who did a year of surgical residency and the Certificate of Added Competence in Emergency Medicine. There is certainly room to reform and enhance it without adding a year. I recall several rotations that did not add value.

As well, I question the ethics of using an extra year of residency to address the human resources issues with rural communities, under the guise of increased confidence. Residents can gain confidence wherever they live, and within the 2-year time frame, as long as their curriculum is well designed.

Finally, I take issue with increasing “complexity” as a lever for this change. Complexity requires more investment by government to offload complicated forms and other administrative tasks. Issues of social complexity require government-sponsored social workers and mental health therapists, not increased family medicine training. Family doctors are trained to manage complex medical cases and do so with ease.

In short, extending residency training at this time will further extend the human resources crisis in family medicine and contribute to patients being treated by providers with considerably less training. The evidence used to promote this change is scant and extending residency does not actually address the concern of increased complexity. Finally, the CFPC should be working for its dues-paying members. Issues such as this should be widely vetted with full transparency before any commitment to change is made.

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