Just family doctors

Preclerkship presence

Preclerkship curricula are focused on secondary care; most institutions adopt a body systems–based approach that does not easily integrate with generalist specialties such as family medicine. As a result, not only do medical students lack exposure to family medicine within classrooms, but the culture of medicine within these early years becomes predominantly defined by the attitude and perspectives of nongeneralist lecturers.

While medicine is a collaborative profession, interspecialty biases continue to be an unfortunate reality. Previous studies have suggested that family medicine is often at the centre of disrespectful discourse.^3-5 Medical students, in particular preclerks who lack their own clinical experiences, often internalize the behaviour and beliefs of their instructors and mentors. Without a strong family medicine presence at this formative stage to provide a counter perspective, the conversation can become skewed against the field. Evidence shows that interest in family medicine substantially increases during clerkship⁶ once students are able to experience the field and dispel negative preconceptions; this can be through innovative models of longitudinal family medicine placements adopted by, for example, NOSM University⁷ and the School of Medicine at Queen’s University in Kingston, Ont.⁸ However, if students fail to engage in these opportunities (eg, enhanced family medicine electives) due to bias, then the efficacy of these programs is hampered. Sadly, in the preclerkship context, comments such as “You don’t need to know the details of [some subspecialized topic] because most of you will just become family doctors” are common refrains during lectures. Such phrasing not only devalues the discipline (“just”), but highlights the unbalanced exhibition of unique field expertise found within preclerkship content. Family medicine is not given the opportunity to showcase its exclusive knowledge base, and so students are often left with the false impression that family doctors lack specialized expertise.

When family medicine is present during preclerkship, it is often not integrated well into the overall curriculum flow. Sequestered at the very beginning of medical school or used as thematic breaks between blocks, family medicine is presented as an introductory topic at best or an intrusive add-on at worst. A better approach to integrate family medicine may be to capitalize on family physicians’ expertise in preventive health by discussing relevant screening guidelines during each block, or to focus on family medicine’s proficiency for holistic patient care when transitioning between system-centric blocks. This approach would not only highlight the strength of family medicine as a comprehensive primary care discipline but also illustrate the importance of collaborating with family physicians across all specialties.

Family medicine placements during preclerkship are now adopted by several Canadian institutions, and have been shown to be successful in improving attitudes and perceptions of the field.⁹ However, such experiences are often treated as extracurricular, as they require time outside of regular teaching hours to participate.^10,11 Building dedicated time into student schedules for such placements, as is done at the University of Toronto in Ontario,¹² better integrates these opportunities into course content and positions them as core aspects of the curriculum.

Specialty status

Family medicine was officially recognized as a specialty in 2007 with the introduction of a 2-year residency program and certification examination.¹³ This change was made to distinguish family medicine from general practitioners and to acknowledge that the field is on par with all other specialties.¹⁴ However, common discourse around family medicine has not reflected this change within medical education. The rhetoric that medical students are “being trained as family doctors” is one prominent example. While this statement is meant to indicate a more generalist approach to medical education, with specialization left to residency, the literal interpretation continues to perpetuate the equivalency of family medicine and general practice—that medical school graduates are equal to family physicians.

Similarly, the term generalist, while not exclusive to family medicine, is often used as an antonym to specialist when applied to family medicine. This lack of acknowledgment of family medicine as a specialty in its own right perpetuates the misconception that family physicians are not field experts.¹⁵ Rather than describe family doctors as specializing in chronic illness management, prevention medicine, longitudinal health, or indeed as specialists in generalist medicine, they are instead portrayed as a jack-of-all-trades but a master of none. In an increasingly subspecialized medical landscape, the value trainees place on field expertise has never been more apparent. As such, this practice of segregating family medicine from other specialties is preventing the field from catering to the evolving interests of current medical students. There already exists a push to redefine family medicine as a specialist generalist, which portrays generalism as a much-needed area of expertise,¹⁶ but the term is not widely adopted.

Another way to change the discourse is to label family medicine as a lifestyle specialty: family physicians enjoy flexible schedules, regular working hours, good work-life balance, and positive patient outcomes. These are all qualities traditionally celebrated in specialties such as dermatology and ophthalmology, which are lauded for their lifestyle advantages, but are not often ascribed to family medicine. The lifestyle specialty label would not only highlight the many benefits of family practice, but also elevate it in common discourse to the esteem of other such labelled specialties.

Discipline desirability

Family medicine is often treated as the default option by medical schools. Conversations surrounding parallel planning frequently include family medicine as the alternative pathway.¹⁷ Students unmatched after the first iteration are routinely advised to apply for family medicine. Several Canadian medical schools require unmatched students to apply to at least 1 family medicine program to be accepted into a clerkship extension year. While this is admirable, the association that advice creates between family medicine and going unmatched paints the discipline as a last-choice specialty. Likewise, the obligatory nature of these policies perpetuates the belief that family medicine is inherently undesirable.

Rather than presenting it as an “or else” specialty by targeting unenthusiastic students with few other options, early incentivization of undecided students creates a more positive impression of the field. Offering greater flexibility during clerkship for those interested in exploring the breadth of family practice (eg, adjusting the Student Elective Diversification Policy¹⁸), increasing hands-on opportunities, having easier processes for multisite residency applications, and changing the terminology from “noncompetitive” to “more accessible” when referring to match rates are some ways to positively encourage students to choose the field without compromising its credibility. The abundance of family medicine residency spots and graduates should be celebrated as a token of the field’s popularity.