Evolving roles of a 3-year family medicine trainee

Better equipped

Now, more than ever, we need family doctors who are confident and who have practised integrating the management of various chronic conditions in the care of older patients. While these patients have more complex needs and their appointments often take more time, I feel more equipped with my extra year to provide them with high-quality care in a family practice setting. My geriatrics training is complementary to primary care because it addresses an aging population that increasingly makes up a bigger proportion of our communities and it takes an integrative, whole-person approach to care. In my weekly family practice clinic, I see isolated older adults with no close relatives who are also troubled with changing cognition, worsening frailty, and an increasing chronic disease burden. I take the comprehensive geriatric assessment done in my fellowship training and integrate it into several follow-up visits in my family medicine clinic. I schedule advance care planning conversations when I recognize social vulnerability to review substitute decision makers with patients, and I revisit goals of care when there is a change in health status. With the additional time that a third year allows, I have been able to evaluate which responsibilities I can delegate to my interprofessional team to ensure I can balance my time efficiently, managing patient flow while still providing good care to older adults. Patients are thankful when they believe their concerns are being addressed holistically—and I get a lot of joy from building longitudinal relationships, knowing that I can help my patients.

Importance of collaboration

One of the most important things I have learned in my additional year of training is all the resources and professionals that are available in the community, both to me and to my patients. Primary care and COE involve understanding what a health condition means for a patient in the context of their life and using that knowledge to help synthesize a plan for moving forward. Recently in clinic, I saw a relatively fit older adult with no psychiatric history who was seeking medical assistance in dying because they were noticing incremental changes in their health status that were unacceptable to them. For this case, I was lucky to lean on staff from both my residency and fellowship programs, who offered advice and expertise. I suspect that I will continue to see more patients with these values who come to me with similar questions. To manage uncertainty and build my own resilience as an independent clinician, it has been important for me to learn how to collaborate with others to devise a plan, rather than attempting to manage complex situations all on my own.

I have always believed that primary care represents the cornerstone of our health care system, but despite the great need for such practitioners in our country, there are fears of burnout for generalist family physicians. I admit that when I hear these things, I worry that the College of Family Physicians of Canada’s proposal to extend family medicine residency to 3 years—which does not include additional fellowship training, as in my case—may deter more trainees from pursuing this specialty.¹

It was my intrinsic motivation that drove me to pursue family medicine with an integrated COE fellowship. I acknowledge this comes from a place of privilege, and not everyone can make education and career decisions based solely on intrinsic motivation. Family medicine is hard but, in my experience, maybe a third year with integrated enhanced skills training can prepare future family doctors with the skills and mental fortitude they will need to provide care in a more complex and more challenging health care environment.

My 3-year integrated fellowship has given me not only the flexibility to practise balancing increasingly complex generalist care and more specialized elder care, but also the time to learn how to integrate facets of these types of care in different settings. I also get to work directly with staff who role model the provision of specialized skills in their generalist practices, and I have been able to build lasting relationships to lean on if I should need more support. As family medicine residencies are expanded to 3-year programs, how can we design them in a way that acknowledges the increasing complexity of generalist care? Perhaps we can learn from these integrated fellowship programs that embrace the broader scopes of primary care providers.