At least 30% of individuals older than 80 years of age are clinically frail.1 Despite this, family medicine residents can graduate without ever having set foot in a nursing home or having made a housecall for someone who is frail. It is time for this to change. Our Dangerous Idea is that the College of Family Physicians of Canada make longitudinal community-based care of the frail elderly (housecalls and nursing home care) a mandatory element of training. The introduction of such programs will provide many opportunities to make a difference in family practice and health care delivery. First, learners will develop their geriatric, internal medicine, emergency medicine, and palliative clinical skills without relying on extensive laboratory tests or imaging, allowing the history and physical examination to return to centre stage in making a diagnosis. Residents will also learn to provide a blend of curative therapy and palliation following patient and family discussions—both the art and science of medicine. As homebound and nursing home patients are a captive audience, there is increased opportunity to develop longitudinal doctor-patient relationships—something that postgraduate programs struggle to provide in office-based learning environments. In addition, when residents are exposed to nursing home and homebound elder care, they must work with a team of other formal and informal providers. This allows them to develop a greater understanding of team-based care. Furthermore, service provision in these settings provides learners with opportunities to see the “context” of the patients’ illness experiences, the determinants of their health, and their support systems and resources. Finally, this requirement would address a growing need for home-based and nursing home primary care as our population ages. It is time to take all trainees to the “coal face,” where very frail elders reside, and allow the next generation of family doctors to develop confidence in this increasingly important work.
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