Should family medicine residents in Canada do a third year of training?

The aim of argument, or of discussion, should not be victory, but progress.

                                                                                           Joseph Joubert

One of the most important, albeit difficult, roles of Canadian Family Physician (CFP) is to create space for respectful evidence-informed debate and discussion about the most important and vexing issues of the day in family medicine (FM).

The College of Family Physicians of Canada’s (CFPC’s) plan to extend residency training to 3 years from 2 to align with many of our international counterparts is one of the most divisive issues in FM today. But it is important for CFP to encourage and frame debate around it.

Many are strongly opposed to such a change, especially at a time when fewer medical students are choosing careers in FM.¹ We know that older FPs have been retiring at twice the rate during the pandemic than in the past,² and more than 6 million Canadians cannot find an FP.³ Opponents fear that a third year of training could further hinder FM recruitment, overwhelm teaching programs, and exacerbate the FP supply problem. Yet supporters fear that FM residents are choosing third-year training in focused areas of practice instead of practising comprehensively after graduation because they feel inadequately prepared to do so in a 2-year program.

Personally—given my role as Scientific Editor of CFP—I have long felt that FM training in Canada should be longer, not to better prepare trainees for comprehensive practice, but for other important purposes: for example, enhanced training in research for all FPs would allow us to be the creators and custodians of our own continuing professional development (and to be less dependent on our specialist colleagues in this area). I am sure few would support this.

One of the most powerful forms of health services research involves linking data sets to uncover a problem in the system. This month’s issue features a study by Dr M. Ruth Lavergne et al (page 550), wherein they examine and describe declining comprehensiveness of care provided by FPs in Nova Scotia, Ontario, Manitoba, and British Columbia between 1999 to 2000 and 2017 to 2018.⁴

They found that declines in comprehensiveness of care had more to do with FPs working in fewer clinical settings, on average, rather than FPs providing fewer office-based services. Although the characteristics of the FP population changed during the study period—years in practice, sex, urban or rural practice, location of training—declines in comprehensiveness were seen across all physician characteristics in all 4 provinces, and they were not explained by generational changes, growing proportions of female doctors, or changes in training.

Since declining comprehensiveness cuts across all FP ages, they argue the CFPC should champion system reforms allowing all FPs to practise in more sustainable ways rather than change FM training length (page 524).⁵

Steve Slade, Dr Nancy Fowler, and Dr Lawrence C. Loh from the CFPC respond by taking aim at some of the limitations of large data set research and the resultant conclusions (page 522).⁶ They argue in favour of a third year of training by citing a large body of research demonstrating that FM training does shape FPs’ future scopes of practice.

As an FP who graduated from a 2-year training program and whose practice data are captured in both time points in this research, I can speak to and reflect on the inadequacy of my training and my declining comprehensiveness.

My training did not prepare me fully for comprehensive generalist practice that for me peaked around 2000, when I ran an FM inpatient unit, did weekly home visits, and provided palliative care, all while running a busy office practice providing full-scope care. Like most new graduates, I got up to speed through initial on-the-job experience. By 2017 my comprehensiveness had begun to reach a nadir, mainly due to system changes such as an aging population, influence of clinical practice guidelines in raising standards of care, greater administrative burdens, and advances in medical care that have made practice more complex.

Can FM residents ever be fully prepared for practice? Likely not, but they are entering a more complex and demanding medical world than I did. It is the responsibility of FM leaders and teachers to prepare them for the future, even if we may not yet agree on how best to do so.

• Copyright © 2023 the College of Family Physicians of Canada