Canada is facing a primary care crisis.1 Primary care plays an essential role in supporting the health of Canadians and makes up the largest component of health care services delivered by physicians in Canada.2,3 In British Columbia, one solution to address the crisis is the development of the first new medical school in Western Canada in 50 years. The Simon Fraser University School of Medicine (SFU SoM) has a mandate to prepare physicians with the skills and experiences to provide team-based, community-level primary care where it is most needed, with an emphasis on family medicine.4 The school plans to graduate its first cohort of medical students in May 2029.5 However, if these graduates are to be part of the solution, the school will need to do more than just graduate qualified individuals with a medical degree.
The SFU SoM will operate within a larger health system in a state of stress. The SoM can design an undergraduate curriculum to graduate doctors that are expert generalist thinkers committed to team-based, primary care. The SoM can also cocreate residency training spots that solidify generalist skills in partnership with local health organizations. However, once the doctors have graduated, the SoM’s direct influence declines. Beyond this, the larger health care system must continue to evolve to provide attractive jobs to which these graduates can apply and use those skills.6-8
Larger system-level issues must be continually addressed for the mandate to succeed. Notably, the SFU SoM is also planning a leading-edge generalist and family medicine and primary care research strategy to identify, design, and communicate solutions that can help the wider primary care context regenerate and evolve in order to improve the chances that their graduates will flourish and that care delivery will be reimagined.9,10
The primary care crisis has developed over decades and is multifaceted.11,12 Some issues, such as the gap between those needing care and the number of family physicians available, are clear, but simply graduating more family doctors will not solve the problem.12-14 A systems-thinking approach15 helps understand the SFU SoM as the tip of an interconnected medical education system that, like an iceberg, has hidden elements that may contribute to the crisis.16 Previous scholars identified design components such as a largely hospital-based clerkship, curriculum and assessment design teams with minimal or no generalist members, and the informal but persistent valorization of subspecialists’ worldview as superior to that of generalists to be part of the problem.17,18
Even though many Canadian medical schools are increasingly emphasizing generalist skills and the importance of family medicine,6,17-20 the effects of these hidden elements are resulting in fewer graduates choosing generalist or primary care residencies.6,17-20 Addressing only the surface issues by, for example, increasing the number of family physician educators, might overlook deeper patterns and structures that have perpetuated barriers to generalist practice.18,21,22 Figure 1 shows the specific focus the SFU SoM has directed toward creating a new standard of undergraduate curriculum design to promote generalism.
The depths of design: Changes for undergraduate medical education as a solution to the primary care crisis.
Medical education deep dive
The history of medical education reveals even more clues about how we came to have the elements that are traditionally below the waterline.23,24 Medical education in Canada (and in the United States) evolved from informal apprenticeships to formal schools.23 A report published in 1910 by an educator named Abraham Flexner, who was commissioned to survey these schools, criticized North American medical education and prompted reforms, including higher standards and scientific rigour.24 These changes emphasized research-based teaching and professionalization.23-25 The Flexner Report shaped the undergraduate structure of a 2-year classroom phase followed by 2 years of practical clerkship in hospitals. More than 100 years later, many Canadian medical schools still reflect Flexner’s 2-plus-2 (or 1.5-plus-1.5) model. While some schools offer integrated community-based clerkships, many rely on hospital-based and subspecialty-focused learning, despite studies showing that generalist teaching leads to more generalist graduates.18,26-28
While the Flexner Report may have advanced scientific discovery in medicine, its focus on biomedicine and hospital-based care may have also inadvertently shifted the focus away from physicians’ primary roles as community-centred, relationship-based healers routinely seeing undifferentiated illness. More directly damaging was the resultant closure of many Black American medical schools, which some experts suggest is a foundational element for the structural racism and underrepresentation we continue to see in medicine today.25,29-32 Black medical schools had less funding and fewer direct ties with established universities and were unable to adapt to Flexner’s new standards. Schools that could make the change admitted mostly or exclusively white students.25 The primary care crisis in Canada had a disproportionate effect on equity-deserving groups.33-37 Studies show that increasing the diversity of the medical school student body, and in the medical workforce more widely, has positive effects on health outcomes for members of historically underrepresented groups.38-40
The Flexner Report had unintended consequences on both generalism and generalist specialists due to patterns in research funding and the narrowed focus of inquiry, which encouraged increasing specialization.41 The Association of Faculties of Medicine of Canada authored The Future of Medical Education in Canada report in the centenary year of Flexner’s report; theirs called for several reforms, including value generalism.42 This shift includes focusing more on continuity of care, addressing the hidden curriculum that devalues family medicine, expanding the range of clinical contexts, and encouraging family physician teachers, among other reforms.
Reimagining the best modern approach
The SFU SoM has the opportunity to take the gems from Flexner’s approach and, within the construct of the requirements of the Committee on Accreditation of Canadian Medical Schools,43,44 reimagine the best modern approach possible. The school is being built on 6 foundational principles: 1) preparing graduates to meet the primary care needs of British Columbia’s diverse population, 2) building team-based and socially accountable primary care, 3) developing reciprocal community partnerships, 4) embedding and equalizing Indigenous knowledge systems, 5) supporting community-centred place-based learning, and 6) harnessing the power of emerging technologies for learning and health care.4 These foundations will be reinforced with strategies aimed at areas both above and below the iceberg waterline (Figure 1).
The 3-year SFU SoM undergraduate medical program curriculum aims to disrupt the traditional Flexnerian 2-plus-2 (2 years of preclerkship followed by 2 years of clerkship, or 1.5-plus-1.5) model that is omnipresent in North American medical education. This new model will incorporate early and continuous community-centred clinical and extraclinical learning opportunities that include purposeful integration of and continuous exposure to generalism, team-based primary care, and family medicine in a variety of settings, including some hospital-based learning. This intense exposure will ensure the graduates are well equipped to handle the diverse needs of patients in different communities and various settings.45
Case-based learning will focus on patient presentations that are common in primary care, recognizing that most care is provided in the community, and that the care provided in inpatient settings is generally reserved for only the most complex care of increasingly sick patients.3 The curriculum will teach and model cultural humility and will integrate Indigenous knowledge systems. A focus on health equity throughout the curriculum46 will reflect the importance of appreciating both how health and well-being are understood by the communities served and how social and structural factors impact the health of these communities. The majority of cases will include co-authorship by a family physician and community member.45
Starting early in the first year, students will have longitudinal relationships with patients, clinics, and communities, which will allow the learner to build key community-based generalist skills and, at the same time, clinical teachers and communities to invest in and benefit from a relationship with a student or students.
By emphasizing community engagement, the new medical school can produce graduates who are not only clinically competent but also socially accountable and attuned to the unique needs of the communities they serve.8,26,47 Partnerships with diverse communities enable medical schools to provide culturally responsive care and better prepare future physicians to respond to the health needs of the province’s most underserved populations.39
Conclusion
The SFU SoM faces some important potential limitations that must be kept in mind as we evaluate how well it meets the mandate for its undergraduate curriculum.4 Our health care system and the primary care providers, in particular, are in crisis. In British Columbia, there are few interprofessional team-based care clinics in operation.48 This lack might have broad implications on, for example, the availability of training and practice locations for students, the number of appropriate residency training sites, and the structure of jobs for graduates to move into. Also, despite targeted efforts to remove systemic barriers to achieving diversity in medical education, persistent structural inequalities in society at large might impact not only the diversity of graduates but also their choice of communities in which to practise. The SoM will soon embark on strategic planning for its research, graduate, and professional development programs, and the need to highlight and address these limitations with government and health system partners will be at the forefront of these efforts.
The SFU SoM is proposing an innovative approach to addressing the primary care crisis; however, its success will depend on more than just producing more doctors. The school’s attention to both the visible and the invisible elements shaping medical education, as well as its focus on generalist skills, community engagement, and culturally responsive care, is vital for shaping future doctors to be prepared to meet the unique needs of our current system and our diverse populations. Challenges such as systemic inequalities, strained health care infrastructure, and limited training opportunities must be continuously addressed to ensure success. By remaining adaptable and committed to social accountability, the SFU SoM can play a key role in evolving Canada’s primary care landscape.
Footnotes
Competing interests
None declared
The opinions expressed in this article are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.
This article has been peer reviewed.
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