I first became interested in medicine volunteering as a musician in long-term care. I connected deeply with the residents and wondered what it might be like as a physician caring for them. In medical school, I discovered that family medicine embodied the values that drew me to health care: continuity of care, compassion, and care of the whole person. Having completed a degree in gerontology, I knew I wanted to focus on care of older adults. By the end of my family medicine residency, my commitment to caring for older people had only deepened, and pursuing care of the elderly (COE) training felt like the natural next step.
When I applied to COE programs in 2024, I braced myself for competition. To my surprise, however, I discovered that COE positions were going unfilled at many institutions. With nearly 1 in 4 Canadians projected to be age 65 or older by 2030,1 I had assumed that more family medicine residents would be drawn to this training. Yet over the past 5 Canadian Resident Matching Service cycles, COE positions have consistently gone unfilled in the first iteration (Figures 1 and 2).2-6
Unmatched care of the elderly positions in the Canadian Resident Matching Service, 2021-2025
Care of the elderly positions filled versus unmatched in the Canadian Resident Matching Service, 2021-2025
Compared to other family medicine “+1” enhanced skills programs, the trend is even more striking.7 Similarly sized programs such as palliative care, addiction medicine, sport and exercise medicine, and family practice anesthesia typically have between 0 and 7 positions unfilled nationwide (Figure 3).2-6 This pattern is worsening despite the demographic imperative, and underscores the urgency to re-evaluate how COE is positioned, perceived, and promoted within our training system.
Unmatched family medicine enhanced skills program positions in the Canadian Resident Matching Service, 2021-2025
The pattern is not isolated to COE. Geriatric medicine has seen the same trend, with unmatched positions rising annually from 10 positions in 2021 to 18 in 2025.8-12 It is consistently the most underfilled internal medicine (IM) subspecialty.
Though COE and geriatric medicine differ in training and practice models, the shared trend raises a pressing question: Why is interest in geriatric-focused training lagging despite overwhelming population need? As a COE resident, I spoke with other learners, including family and IM residents and medical students. The discussions offered insight into the views and perceptions that contribute to this lack of interest. I will address some of these common viewpoints, as they are important to understanding this issue.
But why does this issue matter? Canada needs physicians skilled in caring for older adults and managing geriatric syndromes. The growing mismatch between population health needs and learners’ career priorities is not merely a workforce issue, but a matter of equity, safety, and quality of care for a vulnerable demographic. This challenge is compounded by declining interest in family medicine in Canada, which contributes to the lack of interest in COE training.
Misconceptions
Family medicine is basically geriatrics. I have encountered the assumption that additional geriatric-focused training is redundant because family medicine today is essentially geriatric care. While it is true that many patients who present to primary care are older, most are healthy community-dwelling individuals. Treating frailty, multimorbidity, cognitive impairment, and psychosocial complexities requires a distinct skillset that can stretch the resources of primary care.
COE programs offer a structured year to develop competencies in managing geriatric syndromes in depth, which I have come to truly appreciate at the end of my own training. As a new family medicine graduate, I lacked the confidence to recognize and manage conditions like Parkinson disease. COE training helped me develop this skillset, and I am now comfortable teaching junior learners about the topic. Like others, before my training, I did not appreciate how much additional expertise was needed to provide optimal care for older patients.
There are concerns that certificates of added competence prompt early-career trainees to seek a specialist label, thereby devaluing generalism.13 COE is different than geriatrics. Whereas geriatrics is typically hospital based and consultative, COE maintains strong roots in family medicine by providing community-based care in long-term care homes, outpatient clinics, and patients’ homes. Many COE physicians offer longitudinal primary care, bringing a refined perspective to complex older adults while retaining the breadth of generalist practice. COE enhances the capacity of generalism to meet the evolving needs of an aging population rather than eroding it.
We do not get to fix people. I have encountered the perception that care of older adults is less appealing because there are no quick fixes. This sentiment is particularly common when discussing dementia care, where no curative treatments currently exist. Yet I would argue that this is not unique to geriatric care. In many areas of medicine, even procedural specialties, managing chronic conditions is an integral part of practice. While we may not be able to cure dementia, there are evidence-based interventions that substantially improve quality of life, including social engagement, exercise, and home-based services. Unfortunately, systemic investment in these interventions, as well as home care infrastructure, remains limited. Providing excellent dementia care requires a broader societal commitment to community-based supports and a rethinking of how we structure care environments. Although we may not always be able to fix the underlying disease, we can profoundly affect how individuals live with it and, in doing so, alleviate suffering for patients and families.
I should also highlight that sometimes we do get to fix people. What a difference it can make to unravel a prescription cascade and literally get somebody back on their feet! I have personally found it deeply meaningful and gratifying to make a tangible difference in patients’ lives in the face of chronic illness.
Geriatric care feels daunting; the patients are too complex. Older adults today are living longer with more comorbidities, functional impairments, and multiple medications. It requires patience to work through a list of 20 medications, to recognize and untangle prescription cascades, and to thoughtfully address a problem list of 15 or more active issues. Yet this complexity is the very heart of what makes the practice of medicine challenging and meaningful. Geriatric care demands patience, intellectual curiosity, and systematic thinking that we should aspire to as physicians.14 Moreover, I have found that the longer I practise in this area, the better (and quicker) I am at working through complex problems. What seemed daunting at the outset has become more digestible through practice and patience.
Geriatrics feels like drawn-out palliative medicine. A sentiment I have encountered is that geriatric care is simply drawn-out end-of-life care. This perception reflects, at least in part, underlying ageism: It is the assumption that because patients are in their twilight years, they are less deserving of thorough care. Rather, working with older adults demands a high level of clinical judgment and precision—helping patients and families clarify goals of care, prescribing wisely, and choosing investigations judiciously. In a system that often rewards doing more, caring for older adults requires the challenging skill of doing what matters most.
There are no financial incentives. The deficiencies in how our system financially supports COE cannot be ignored. Many COE physicians work within traditional fee-for-service models, which are not well aligned with the time-intensive, complex nature of geriatric practice. While alternative funding plans (AFPs) exist in some settings, access remains variable across provinces and institutions.15 The current system tends to reward volume over complexity, creating structural disincentives for those providing comprehensive care for older adults in COE and family medicine practices. Concerns about practical barriers to career choice have been accentuated by a possible change in family medicine training from 2 to 3 years. But change is possible: AFP models and other blended funding models are gradually expanding, offering better alignment between clinical work and remuneration. Until remuneration better reflects the realities of geriatric care, interest in COE training may continue to lag behind population needs.
Limited exposure and marketing? Lack of exposure to geriatrics during training is often cited in this discussion, but most Canadian medical schools and residency programs include mandatory geriatrics rotations, and trainees encounter older adults across most spheres of clinical care. COE programs have been proactive in advertising training opportunities via information nights, like other enhanced skills programs. While exposure during training is necessary, it does not appear to be the main issue. A more pertinent question may be: How early and in what manner does exposure need to happen to impact career decision-making?
Future directions
Geriatric-focused practice is a source of deep professional satisfaction. The American Geriatrics Society highlights that geriatricians rank among the most satisfied health professionals, citing encounters with inspirational older adults, deep and meaningful relationships, and steady work hours as factors.16 In Canada, COE physicians are uniquely positioned to serve communities by combining the broad, community-centred philosophy of family medicine with skills tailored to the care of complex older patients. COE training may lead to a focused practice or to optimal comprehensive practice; either way, they will be providing care to an important and vulnerable sector, applying the best principles and skills of family medicine.
Future directions should include engaging medical trainees via focus groups or surveys to understand perceptions of career choices, identifying barriers early, and testing interventions such as earlier positive exposure to the field, potentially at undergraduate or even secondary education levels. Structural reforms—such as expanding AFPs and piloting innovative care models that value time-intensive, complexity-driven work—will also be essential. Shaping a future where caring for older adults is seen as a core, rewarding part of medical practice will benefit both our profession and Canadian society as a whole.
Notes
First Five Years articles are coordinated by the First Five Years in Family Practice Committee of the College of Family Physicians of Canada. The goal is to explore topics relevant to newly practising physicians, as well as to all Canadian Family Physician readers. Contributions are invited from those in their first 5 years in practice. For more information, or to submit an article, contact Lissa Manganaro, Manager, Member Programs, at lmanganaro{at}cfpc.ca.
Footnotes
Competing interests
None declared
This article has been peer reviewed.
La traduction en français de cet article se trouve à https://www.cfp.ca dans la table des matières du numéro de février 2026 à la page e35.
- Copyright © 2026 the College of Family Physicians of Canada
