Evolving roles of a three-year family medicine trainee: Perspectives from integrated enhanced skills training

In a few months, I will finish a three-year integrated family medicine residency and care of the elderly (COE) fellowship. The integration of COE specialist training throughout my residency has given me the confidence to work as a primary care generalist at a time where healthcare issues are much more complex. Instead of the classic “2+1” model where a traditional two-year family medicine residency may be followed by a one-year fellowship, the integrated program is unique because the traditional one-year COE fellowship is incorporated throughout my training, thereby extending my residency from two to three years. I acquired much of my scientific, algorithmic knowledge during my first two years of training, and confidently wrote the CFPC exam after this timeframe. However, it was in my third year of combined residency and complimentary fellowship training where I refined the practical and nuanced aspects of caring for older adults, which ultimately makes me feel more prepared entering the changing landscape of primary care. Choosing to finish my generalist and specialist training at the same time was important for me to prepare for the integration of both skillsets in my future practice. Being near the completion of the pilot of this program, I hope my various experiences can contribute to the current discussion of a three-year family residency program.

Now more than ever, I believe we need family doctors who are confident and have practiced integrating the management of various chronic conditions in an older patient. While these patients are more complex and often take more time, I feel more equipped with my extra year to provide them with good quality care in a family practice setting. My geriatrics training is complementary to primary care because it both addresses an aging population that increasingly makes up a bigger proportion of our communities, and also takes an integrative, whole-person approach to care. In my weekly family practice clinic, I see isolated older adults with no close relatives who are also troubled with changing cognition, worsening frailty, and an increasing chronic disease burden. I take the comprehensive geriatric assessment done in my fellowship training and integrate it into several follow-up visits in my family medicine clinic. I schedule advance care planning conversations when I recognize social vulnerability to review patient substitute decision makers, and revisit goals of care when there is a change in health status. With the additional time that a third year allows, I am able to trial and practice which responsibilities I can delegate to my interprofessional team to ensure I can balance my time efficiently, managing patient flow while still providing good care to older adults. Patients are thankful when they feel that their concerns are addressed holistically – and I also get a lot of joy building longitudinal relationships, knowing that I can help them.

One of the most important things that I have learned in my additional year of training is all the resources and professionals that are available in the community, both to me and to my patients. Primary care and care of the elderly both involve understanding what a health condition means for a patient in the context of their life and using it to help synthesize a plan forward. Recently in clinic, I saw a relatively fit older adult with no psychiatric history who was seeking medical assistance in dying because they were noticing incremental changes in their health status. For this case, I was lucky to lean on staff from both my residency and fellowship programs who offered more advice and expertise. I suspect that I will continue to see more patients with these values who come to me with similar questions. To manage uncertainty and build up my own resilience as a future independent clinician, it has been important for me to learn how to collaborate with others to come up with a plan, rather than managing the complex situation all on my own.

I have always believed that primary care represents the cornerstone of our healthcare system – but despite the great need in our country, there are fears of burnout as a generalist family medicine practitioner. I admit that when I hear these things, I worry that extending family medicine training to three years may deter more trainees from pursuing this specialty. It was my intrinsic motivation that drove me to pursue family medicine with an integrated COE fellowship. I acknowledge this comes from a place of privilege and not everyone can make their education and career decisions based solely on intrinsic motivation. Family medicine is hard, but in my experience, maybe a third year with integrated specialist training can prepare future family doctors with the skills and mental fortitude to provide care in a more complex and more challenging healthcare environment.

My three-year integrated fellowship has given me the flexibility to not only practice balancing increasingly complex generalist care and more specialized elder care, but also the time to learn how to integrate facets of these types of care in different settings. I also get to work directly with staff who role model the provision of specialized skills in their generalist practice and build lasting relationships to lean on if I need more support. As family medicine residencies are expanded into three-year programs, how can we design them for the increasing complexity of generalist care? Perhaps we can learn from these integrated fellowship programs that embrace the larger scope of primary care providers. I chose to complete a family medicine residency because I believe in the importance of providing primary care in our communities. My integrated fellowship has given me the confidence, fulfillment, and resilience I need within the changing landscape of primary care as I start my career in family medicine.

Acknowledgment
Many thanks for the support of colleagues and mentors at the University of Toronto Department of Family and Community Medicine, Sunnybrook Health Sciences Centre, and Baycrest Centre. Special thanks to Dr. Amy Freedman, the Care of the Elderly program director at the University of Toronto.