Enhanced skills for the future of family medicine: The changing landscape

At the Family Medicine Forum 2022, an open session was hosted to allow input from members on Enhanced Skills in Family Medicine and how best to integrate these into our broad scope to better meet evolving needs. Gathering opinions from as many family physicians as possible to inform changes was the goal of this session. As facilitators, we sought to engage participants. We opened the session with a review of the key areas of focus including whether there is a continued need for Enhanced Skills training, areas of persistent training gaps, and a reflection on the proposed move to a three-year residency in Family Medicine.

The access crisis for comprehensive care, catalyzed by the COVID-19 pandemic makes the timing of a move to lengthier training precarious and perhaps short-sighted.

Following this brief introduction there was a fulsome discussion with facilitated open-mic style interactions for the remainder of the hour. Included in this conversation were several current and former leaders in Family Medicine, urban and rural voices, and the academic perspective, which provided for broad and fruitful interactions. The conversation continued beyond the allotted time in engaged groups in the hallway; this is a discussion that was both welcomed and needed.

What We Heard

The comprehensive cradle-to-grave care of the past is seldom feasible for Family Physicians. Team-based care is now the norm and Enhanced Skills training is both desirable and necessary to meet community needs. The overwhelming sentiment was that interprofessional, multi-practitioner models are both necessary and most of the time desirable for effective and efficient comprehensive care in today’s complex healthcare system.

In Canada today, Family Physicians are overworked, and their compensation is far less than most other specialists(1). The levels of burnout are staggering. Left behind by a healthcare system that values specialism, technology, and intervention, Family Physicians and patients in Canada have been left without a medical home. The crisis is evident on wait lists, Emergency Department overcrowding, and many other practitioners have moved into this space with variable and unstudied success.

Family Medicine is the victim of hidden curriculum in medical training both in class and at the bedside. The fact that the Four Principles of Family Medicine pre-date CanMEDS by more than a decade has been neither highlighted nor celebrated. (2,3) We led the charge for patient-centered, community responsive, and skilled care in Canada and nobody noticed. Not even us.

What We Have Now

The current model for Enhanced Skills intended to meet niche community needs to compliment broad-based Family Medicine. (4) This has not been the case for many practitioners, which is exemplified by Emergency Medicine Enhanced Skills programming. These are the most common of the Enhanced Skills programs, and they are also the only one with a terminal examination having over 90% of graduates from this training practice full-time Emergency Medicine.(5)

Questions Posed by Family Physicians in Attendance at the Session

• Might a three-year Family Medicine program include skills focused on the intended community of practice?
• Do we know the problem we are trying to solve?
• Is there evidence that longer training is the answer?
• Have other models such as graduated, mentored practice over the first year been considered?
• Why have we not been consulted more rigorously?
• Why are urban academic physicians the sole leaders of this endeavour?
• How will we integrate the new program with what we have?
• Is the vision that Enhanced Skills will be phased out?

Concerns of the Participants

Access

There was a general sentiment that consultation concerning extension of core training to three years was too focal. More training positions in Family Medicine is a platform everyone could support that may be a more logical first step; however, work is also necessary to increase interest in Family Medicine amongst medical school graduates. Many Family Medicine positions remain vacant in the Canadian residency match. (6) Tackling the work necessary to reduce anti-generalism hidden curricula that exists throughout medical education, better remuneration and support to develop collaborative practices would serve to reframe and perhaps ‘refame’ this specialty. Working collaboratively to support International Medical Graduates to enter Family Medicine practice is a viable solution in our opinion as more than 60% practice in Family Medicine. (7) Would the public support this move to reduce the number of graduating Family Physicians by a cohort over the next five years?

Fear

Working in medicine is described as practising because mistakes and unknowns are inevitable. Any physician will feel untethered when first in practice. This is not unique to generalism. Fear and uncertainty lead to excessive testing, poor attitudes toward those underserved or more complex patients, and anxiety. (8,9) Does training exist that is comprehensive enough to provide direction and comfort for each encounter for a practice in generalism?

Support Models

Perhaps training models based in specialism that focus on the mistakes made and misses by Family Medicine over the many, many, successes of this discipline undermine the confidence of our trainees across the continuum of learning. We envision support models in which new physicians have mentors, time to return for additional training and reduced workloads for the first year or two in practice. Developing and instituting models that provide service and allow for enhancements real-time while allowing the provision of safe and high-quality care. Frameworks that include ongoing teaching, mentorship, discussion groups and opportunities to practice technical skills are weak at best and require urgent attention. Can we develop an approach to mitigating these gaps across the continuum of learning in medicine?

Persisting Gaps

Gaps persist in training in many facets of general medical care, including but not limited to occupational medicine, pediatric and adolescent mental health, dermatology, prison medicine, environmental medicine. These areas of critical need in the house of medicine are not well provided elsewhere, despite some of these areas residing under domain of Royal College specialty training. Training in these areas may be variably needed as enhanced skills, based on practice location and focus and on community needs. The need for more Family Physicians equipped to manage these presentations effectively was identified. Can we meet the complex needs of our communities without lengthier training and will we meet them better after three years?

Timeline

The aggressive timeline to implement these significant and yet unproven changes in training seems unrealistic. Time to review other paths to success, value Family Medicine and regain the ground lost in the past decades will be eclipsed by aggressive planning, program roll-out, and evaluations leaving little if any space for the reflective practice we bring to the bedside. Can this program be well informed, and will it provide renewed interest and value in Family Medicine moving forward?

Leadership input

Leaders in Family Medicine from across Canada are committed to Enhanced Skills training to meet patient needs, provide specialized expertise in areas of interest, and better serve the communities in which we practice. The move toward a three-year program does not change any of this commitment. Has leadership welcomed all voices to the table?

Conclusion 

Leadership has expressed interest in capturing these perspectives from practicing Family Physicians and must now move to an inclusive and broad consultation that has not yet taken place. 

Our standing room only session of engaged and concerned members of our College at the Family Medicine Forum, who continued the conversation beyond the end of the session, bears witness to our need for a voice in this important discussion. These folks exhibited great engagement in the care of our patients and communities. Most were keenly interested in broadened opportunities for Enhanced Skills training to help meet the medical needs of communities they serve.

Thank you to those who came to share their views with us. We hope we have reflected the conversation in its true light. 

References

1. https://invested.mdm.ca/how-much-do-family-physicians-make-in-canada/. Accessed April 24, 2023.

2. Rosser, Walter. "Sustaining the 4 principles of family medicine in Canada." Canadian Family Physician 52.10 (2006): 1191.

3. https://www.royalcollege.ca/rcsite/canmeds/about/history-canmeds-e Accessed February 15 2023. Accessed April 24, 2023.

4. Standards for accreditation of residency programs. Mississauga (ON): College of Family Physicians of Canada; 2000.

5. Chan, Benjamin TB. "Do family physicians with emergency medicine certification actually practise family medicine?." Cmaj 167.8 (2002): 869-870.\

6. https://thevarsity.ca/2023/04/01/canada-needs-more-doctors-why-is-it-so-hard-to-get-into-medical-school/. Accessed April 24, 2023.

7. https://healthydebate.ca/2019/03/topic/international-medical-graduates-and-carms/. Accessed April 24, 2023.

8. Wayne S, Dellmore D, Serna L, Jerabek R, Timm C, Kalishman S. The association between intolerance of ambiguity and decline in medical students’ attitudes toward the underserved. Acad Med. 2011;86(7):877–882.

9. Bachman KH, Freeborn DK. HMO physicians’ use of referrals. Soc Sci Med. 1999;48(4):547–557.